On behalf of AOFAS, I want to welcome you to tonight's program, Putting It Into Practice, Pediatric Foot and Ankle Pathology. Our webinar will be moderated by Tracy Herring and Dr. Brandon King. Our faculty tonight are Dr. Jacob Zeid, Katelyn Kolosi, Dr. Terrence Ishmael, and Dr. Lisa Zelbe-Silverstein. You can find their full biographies and disclosures in the program document posted in the chat box and in the AOFAS On Demand Education Center. The program is provided free of charge with funding from the Orthopedic Foot and Ankle Foundation. To support education programs like this, make a donation to the foundation on our website or by texting GIVE AOFAS to 41444. I'd like to run through a few housekeeping items before we kick off the presentations. For technical difficulties, please try closing your browser and logging back in the same way you did the first time. Registered attendees may earn one and a half hours of AMA PRA Category 1 CME credit by completing the evaluation and CME claim form at the end of the webinar. You can find the link to claim CME in the chat tab, and we will follow up with an email following the conclusion of this broadcast. This webinar is being recorded and will be available for on-demand viewing on the On Demand Education Center content library in approximately 24 hours. We encourage you to ask questions during the presentations. To send your questions to the faculty, click on the Q&A tab on your navigation bar. If you cannot get to your question during the live broadcast, the faculty will reach out to you following the broadcast to respond. Finally, we'd like to invite you to become a member of the AOFAS for access to a global network of orthopedic foot and ankle specialists, high quality journals, and discounted registration for meetings and courses like our upcoming annual meeting in Louisville, Kentucky. I'll now turn the program over to Ms. Herrig and Dr. King to begin. Welcome everybody. We have a good program started today with some really good speakers. I'm Brandon King. This is Tracy Herrig, and we're going to start with pediatric deformity and flat foot, then we'll go to some trauma, tight heel cord, a discussion from a physician and physical therapy approach, and then we'll do our discussion. If we can, after every presentation, we can try to hit some questions, but we might have to save a lot of them for the end just to make sure we get to everything. So I'm going to just, because we don't have a lot of time, I'm going to go ahead and just get started with our first presenter, this is Dr. Zaid. He is currently at Baylor University Medical Center. He is the director of the foot and ankle fellowship there, also a clinical associate professor at the Texas AMM Health Science Center College of Medicine, also the co-director of the Complex Adolescent Foot and Ankle Deformity Clinic at Scottish Rite. There's probably some other things I'm missing, but I'll turn it over to you, Dr. Zaid. Thank you very much. All right. Good evening, everyone. Let me just share my screen real quick, and hopefully someone will tell me if you can't see this, but hopefully you all can. Okay. So we're going to talk about evaluation and management of pediatric flexible flat foot deformity. The, let's see here, there we go. So I don't have anything relevant to disclose for this talk. I do want to talk about just real quickly my perspective and who I am and why I'm the one giving this lecture. So I'm a foot and ankle fellowship trained adult orthopedic surgeon. I ended up at the beginning of my practice, starting a clinic at Texas Scottish Rite with a pediatric orthopedist, which has been going on now for nine years that we'd call the Complex Adolescent Foot and Ankle Deformity Clinic. And so we see a ton of this stuff and take care of a ton of these kids. It probably is 20 to 25% of my practice at this point. And so it's, and I'm pretty passionate about it and passionate about how we take care of these young people. And so that's where I'm coming from with all of what I'm going to talk to you about. So what is a pediatric flexible flat foot? Well, it is the number one reason for consultation in pediatric orthopedic clinics in the United States of America. And there's a little bit of a question as to whether this is a deformity or just represents a normal variation in anatomy. And it probably leans toward the latter, although there are some of these that are real deformities. There are definitely real pediatric foot deformities out there. This doesn't necessarily fall into these sorts of categories. These I don't think anyone would argue are variations of normal, but there have been plenty of studies to go through and assess the arch in children. And this is sort of a classic study from 1987 in JBJS. And this is a nice line, flat feet are usual in infants, common in children and normal range of observations in adult feet. And they just sort of went through and showed how position changes over time and all kids start out with a flat foot and something like in three to six year olds, about 45% of kids have a flat foot. And that corrects to about 10 to 12% of people when they're in their early teens. And so this is just sort of a normal part of development. And then there've been other studies to look at whether or not we can change the natural history of the development of foot position. And this is a nice example of that, where they took about 130 kids, young kids aged one to six, and gave them different types of orthoses to wear in their shoes, and they had a control group. And essentially the bottom line of the study is that nothing really changed in anything. They had no impact on the natural history, the kids in the control group developed an arch over time. And so did the kids who got orthotic, so there's really no reason to intervene. And so this is the key slide of the whole presentation, and you can turn off after this, but flexible flat feet are part of normal developments, and there's absolutely no treatment indicated for an asymptomatic flexible flat foot. And you can just send those kids straight back home. So when they come in to see it, I think the first and most important thing to figure out is why are they there? There's a lot of reasons, it's not like your adult patients coming in. Sometimes they come in just because the deformity is there, they don't have pain, they don't really have problems, it doesn't bother them in any way, they just want to make sure there's nothing wrong with them as a human being, so that's a reason. Another reason is parent concerns, and you'll see this a lot, especially on the younger end of the spectrum. You'll have kids come in with really flat feet, and parents will say, doesn't this need to be fixed, and my kid doesn't have an arch, and doesn't this mean they're going to be like a bad athlete, or doesn't this mean that they're going to get arthritis when they're older and cause all kinds of problems, and the answer to all of that is probably no for most of them. And in fact, I tend to tell them, especially with the ones who talk about athletics, like if any of you see high-level athletes, football players, basketball players, they have some of the flattest feet I've ever seen, and they're doing just fine. And then patient concerns, so some of these young kids will come in, and they don't necessarily have pain, but they're worried about the cosmetics, they're embarrassed about their foot shape and how it looks in front of their friends and other kids, and that's not really a good reason to intervene, but that is part of it, and we'll get a little bit into the psychology of this stuff later on. And then a lot of them will come in for a second opinion, they'll be told by somebody else, oftentimes their pediatrician, ooh, you got this really flat foot, you better go get that checked out, see if you need a surgery, and so it gets sort of implanted in the kid's head and the parent's head that something needs to be done, something's abnormal about their child. But once again, I will refer you back, this is part of normal development, and no treatment is indicated for an asymptomatic flexible flat foot. But there are some kids who come in for pain, and pain is different, and pain is what we're really needing to talk about here, and that's when we need to actually start thinking about some sort of treatment to take care of these kids. So you see a painful flat foot, and then automatically in your head you make your differential, right? Chances are it's going to be a flexible standard flat foot deformity, but other things that go on that list, an accessory navicular, a coalition, perineal spasm or some other sort of neurogenic deformity, an over-cracked clubfoot deformity that had a surgery when they were a kid, a congenital vertical talus, like the x-ray shown here, that was untreated or at least inappropriately treated as a child and now has this ridiculous flat foot. I will tell you what it is not, it is not posterior tibial tendon dysfunction in a young person. I see a second opinion for this more commonly than I would like. Kids don't get posterior tibial tendon dysfunction or posterior tibial tendon tearing, it's not a thing. Sometimes they will get like a tendonitis. Usually when you see that though, it's like in an athlete and it's usually not associated with deformity, and if you do see a kid who has like posterior tibial tendon pain, just as an aside, I would tell you it's probably some sort of proximal muscle asymmetry, it's probably, I mean, I can't wait to hear what the physical therapist on the call has to say about it, but it's almost always, in my experience, they have some sort of muscular asymmetry up high, they're glued throughout, you'll ask, you say to them, you know, do your hips hurt, do your knees hurt? Oh yeah, my hips were hurting, and you send them to PT and they work on their hips and all of a sudden their foot pain just goes away. So then you start examining them, you do standing examination, you do their double limb heel rise to see if their valve is correct to a varus hind foot position indicating flexible deformity because that posterior tibial tendon functions to invert the hind foot, and then just as a quick aside, I just want to talk about the difference in hind foot position and hind foot motion, just sort of as part of the discussion, I don't know if this is the best place for this slide, I just couldn't think of where else to put it. When you look at a hind foot, when the patient is standing, you're looking at their hind foot varus or valgus, that is the static position of the foot, but when you assess hind foot motion clinically, you are looking at a rotation, that subtalar joint doesn't tip into varus and valgus, right, it rotates, and so when you internally rotate the subtalar joint, that brings the heel into a varus position, when you externally rotate it, it brings it into a valgus position, and so it's just a little bit of food for thought, just thinking about what you're doing when you're actually examining this patient, which I'm going to show you in a second. So then you go to your seat examination, all of these kids have a gastrocnemius or Achilles contracture, super common and definitely part of the pain, assuming that they have the standard areas of tenderness and pain, which are the plantar medial foot, where the tailor head is driving into the floor, right, the tailor foot plantar flex, and they have a tight calf and it's driving their tailor head into the floor, so that tight gastrocnemius is problematic for that reason, and the other place that they'll get pain in a flexible flat foot is they'll have sinus tarsy pain from impingement, now if they are having pain elsewhere, you need to start thinking about other things on your list of your differential, right, accessory navicular pain, coalition pain, et cetera, and so on, or does it have nothing to do with the flat foot at all, just because there's a flat foot doesn't mean they can't have another problem, and then you need to assess their hind foot motion, and I just have a couple of quick videos here that I made in clinic, this young woman was there for something unrelated, but I just realized I didn't have a video of this and I wanted to get one for you, so when you assess hind foot motion, you've got to dorsiflex the ankle to a neutral position, when the foot is plantar flexed, it leaves the narrowest part of the tail in the ankle joint, and you'll get a contribution of ankle motion, get tons and tons of motion out of this foot, as opposed to, as opposed to here, when you dorsiflex the tail and bring the wide portion of the tail into the ankle mortise, that'll stabilize the ankle, and then you can assess true subtalar motion, or there's too much motion on that left-hand video, you should only get about 10 degrees of, I'm sorry, of eversion, 30 degrees of inversion, and I would just put to you that when you're examining pretty much any foot, I would recommend that you start working on assessing subtalar motion and getting a sense of normal, because small restrictions in motion may not jump out at you, but they can tip you off that the flat foot is actually there and related to a coalition or some other pathology, and so you just sort of want to start working on assessing subtalar motion and how to do it appropriately. If you do, oh sorry, one more, here's assessing the forefoot, this is something that is a common question, I don't know if you guys can see my cursor, on the left-hand image, but the right foot, what you're looking at is you're looking at the heel and valgus, and then those smaller bones represent the metatarsal heads, right, you're looking at it straight on, and so when the heel is in valgus, the forefoot is in a neutral position. When we talk about forefoot varus or forefoot supination associated with a flat foot, what you're talking about is that when you correct the heel position, as in the left-hand image, and bring the heel to a neutral position, all of a sudden the first metatarsal head is way up off of the floor and the forefoot is in varus. I'm going to show you that in this video, sorry it's a surgical video, but you dorsiflex the ankle to neutral, but only by holding the fourth and fifth metatarsal head, stabilize that lateral column, and then you assess the first metatarsal head position, and if you can dorsiflex it up such that the forefoot is in varus, then you know that you're going to, if you're going to do something surgical, you're going to have to correct that medial column. Okay, if you see this when you walk into the room and the patient is sitting this way with a gross asymmetry between the two sides, this is a, on this kid, this is a right foot coalition until proven otherwise. Come in, the foot is sitting in dorsiflexion, eversion, it is stiff, this is a coalition, and you have to recognize this when you walk in the room. It also makes you look smart. If, like I said, we're going to talk all, this is only about flexible flat foot, if you do have a stiff flat foot, Sam Ford, who's a good friend and an excellent surgeon in North Carolina, as well as Tony Riccio, who's my partner at Scottish Rite, and I, we all wrote this here talking about how to manage stiff flat foot for me. It's a little bit of a different animal. X-ray evaluation, we usually get ankle and foot films. You want to see if there's a contribution of ankle valgus to a kid like this. You need to know how much of the deformity is coming from the ankle versus the foot. You get standard foot films. There they are. So that you can look at the AP and lateral Taylor-first medial axe should be in with each other, not broken like this. You can assess on coverage of the Taylor head. You can assess calcaneal pitch and there are a variety of other radiographic findings. These are the ones that I tend to use the most frequently. You don't really need X-rays technically in a flexible flat foot form. I tend to get them as part of my standard patient evaluation. They don't start out with X-rays. What are you really looking for on the X-ray? You're looking for a coalition. So here you see a C-sign, which is associated with a Taylor calcaneal coalition. Here you see Taylor beaking, which can be associated with any sort of a hind foot coalition. And here you see the true calcaneal navicular coalition on the oblique view where the anterior process of the calcaneus is connecting to the lateral navicular. Do you need to go and get any advanced imaging? Not usually, unless it's a stiff deformity. Advanced imaging, if it's a stiff hind foot, then you're going to start thinking about getting something though pretty quickly. So considerations and treatment. So like I said earlier, it's a different discussion with kids. You want to talk to them about when it hurts. Is it only during sports? Is it only at the end of a tournament weekend of soccer? That is going to impact how you're going to treat them. You want to know what it stops them from doing. What can't they do as a result of their pain? How much is it impacting their life? They oftentimes have a harder time if you just say, what is the doctor doing? You may need to give them examples. Does it stop them from doing things that make them happy? Can they not play sports anymore? Or are they not going out with friends because their feet hurt so bad when they're out and about? They can't stand for long enough. What's their expectation from their treatment? What do they think they're going to get out of this? I had a kid come in and see me and want his foot corrected because he thought it was going to make him be able to slam dunk a basketball. And I said, you are out of your mind. And then there are other kids that come in that, or parents especially, who come in and say, I want my kid's foot corrected. And you say, well, I'm not sure that their pain really is indicative of the need for a surgery. I'll say, no, no, no, no. I think they really, really need this. They hurt at the end of five games of soccer. And then you tell them what the surgery entails and what the recovery involves. And then they go, oh, maybe we don't need that. And like I said, there's some real psychological considerations here, especially in kids. Teenage life is hard. And I mean that very seriously. There is a lot of pressure from parents, school, coaches, friends, and so on. There's bullying. There's hormones in romantic life. There's cosmetics and what you look like. There's a lot to this. And diving into this and figuring out what is bothering these kids is really, really important if you think you're going to get a good outcome out of any treatment that you choose. And then surgery is scary. Some kids actually end up due needing surgery. And those fears of surgery can really hold them back. And so there are times, many times in fact, where we involve a child psychologist with these kids to help them sort of manage their fears associated with the deformity or the rest of their life associated with their foot and how it plays into their feelings of pain. All right. So now let's talk about treatment. So the nice thing about treating these is that it's pretty straightforward. In a flexible flat foot deformity, there's a Cochran review. And basically what they said is asymptomatic. As we said, no treatment. First thing is you try generic foot orthosis, and third, you go operative. For me, my sort of standard first-line treatment is really focused on education, right? That's a big, big part of it as with any pediatric problem. Making sure that they're in good shoes. If they come in and they're just wandering around, you know, their Keds or their Vans or whatever, something that's unsupportive, if you get them into a decent running shoe, they'll feel a lot better. A soft over-the-counter orthotic like this one here. I don't like hard orthotics. I don't like anything with plastic or firmness to it. I think it causes more problems than it helps. But something with a medial heel wedge, a little bit of an arch support is really helpful in a lot of these kids. And then stretching their calves out. A lot of the time, I'll start them out with one of these little foot stretchers. It's hard to get kids to participate in home stretching programs. And if they're really tighter, they're just like not following orders and you think it's going to help them a lot, then getting physical therapy involved can be really helpful as well. And so really quickly, I don't think I've hit my 20 minutes yet. I'm just going to show you one surgical case because I am an orthopedic surgeon and how could we do any talk without showing you guys a surgery. So here's a 14-year-old girl who has failed her conservative treatment and has daily pain, limiting her activity. Here's her obvious deformity and here she is walking. And this is an impressive one to be sure, because I have to show you something impressive from my talk. And she's got quite a bit of deformity here. It's all coming from her foot, nothing in the ankle. So these are my indications for surgery in this patient. She's had a failure of prolonged non-operative treatment of at least six months with orthotics. She has an expected site of her pain at the plantar aspect of her tailor head and it's minus therapy, maybe some callus indicative of her overload at that plantar tailor head. And then she has pain that interferes with her activity. And so this is an article written by another friend of mine named Maurice Bouchard, which sort of goes through the algorithm for how you perform these, which is essentially what I use. So firmness recession, here's just a picture I stole from the internet because it's hard to show this clinical photo. I tend to do a strayer for most of these kids. They're usually pretty tight and we'll do that. They have a true short lateral column. And so you need to lengthen their lateral column, but before you can, you need to lengthen their perineus brevis because it will restrict the amount of deformity correction that you can get out of their calcaneal lengthening. And then once you've lengthened their perineus brevis with the Z lengthening, you do what's called an Evans osteotomy where you cut through their calcaneus and you gap it open with this distractor and you put in a piece of allograft right here to fill that gap. And what that, this is showing what that does. So this is me spreading that osteotomy apart right here and you can see it correct the abduction on that left side. And you can see it creating the arch on the right. So it brings the heel out of valgus into neutral or varus or sort of however much correction you dial in. And then you can hold that usually, oftentimes actually now, I don't use anything to hold it. You just shove the graft in there and it's pretty stable, but you can use a pen if you need to. Then as I showed you guys earlier, you can check for foot deformity. Almost all of these kids need some sort of medial column osteotomy. It's very rare not to. But so you check it and then you do the osteotomy and this is me opening the medial cuneiform. I like to do a dorsal opening wedge on a plantar closing wedge in order to correct that forefoot position from varus into neutral. And then you go over to the medial side and now they have all this redundancy immediately of their posterior tabial tendon and spring ligament. And so what I do is I take a little section out of the spring ligament here and I reef it closed and I tighten the spring or tighten the posterior tabial tendon. So you've taken a little section out of the spring and now you'll see what happens when I close that down. So that's after the graft goes in laterally, it'll close that little space down. You can tie that together and then you can do a little imbrication and weave of the posterior tabial tendon together to tighten it up. And then last, you go to your tabial tendon at the very end of the case. And so this is showing the correction of the right side, which looks very nice. And then here's her x-ray correction. Here's after both sides are corrected. Real quick, I have to belabor this. So in summary, all right, so asymptomatic deformities required in a patient who is symptomatic, who has pain attributable to the deformity and who has failed to respond to non-surgical treatment. That's for me, for the surgeon, you're talking about surgical treatment. And then as we discussed, you really need to consider the patient goals and make sure that... So these are my three munchkins and I think I got that in under 20 minutes. Hopefully I didn't go over. Thanks so much. That was great. Thank you. We actually just have two questions. So I guess if you don't mind, I was gonna maybe see if you could address them now. One is the sinus tarsy implants, the arthroresis screws. Do you find utility in those? I am very anti the arthroresis screws. I have seen them work. They're not pure evil, but I've also seen them cause real pain and problems. And I don't understand them. They don't make sense to me. I don't like shoving something into a joint that doesn't make sense to me and trying to pop that joint open. I don't think that the risk is worth the reward. And so I'm pretty anti, I would say. And the other question is related to kids coming in with kind of vague foot pain, sometimes isolated knee pain with a flexible flat foot to the point where they're considering surgery. And I guess the question is the relationship of a flat foot to a knee deformity. Do you find that they get better when you address their flat foot? Yeah, there's been a lot of, no, there's not really any, at least not through studies. There's no proven association between flat foot and knee pain. We tend to treat them pretty separately, except for, I mean, in an otherwise normal healthy child, not a syndromic kid or someone who has some wild amount of deformity like the kid I showed who has renal osteodystrophy, not stuff like that. But in an otherwise normal healthy child, there's not really an association that's been shown between foot problems and knee pain. And then just one last question, I guess, is when do you call it failure of conservative management? I guess, how far do you go? Yeah, so for me, so I tend to push them. I'll tell them I want them six months in the orthotics. And I want to have a couple of conversations with the kid and the family. So like I said, I want pain, and I want pain that stops them from doing things that they like to do. It's not enough for me if a kid comes in and says, I have 20 minutes of pain at the end of playing a soccer match. Or if I walk for three hours, I start having a little bit of pain, right? That is not acceptable to me. Because if the majority of their life, 98% of their life, they are pain-free, and they're expecting to get improvement in that other 2% out of the surgery, then I don't think that I possess the ability to provide that for them. And what I tell the patients is I say, listen, I say, if you're having five out of 10 pain every day, 95% of the time that you're walking, it hurts, and I do a surgery on you, and you end up with one out of 10 pain, right? It's not a home run, but we do really good. We get you from five to one, and you're going to have one out of 10 pain the rest of your life. That's a pretty good deal. But if you have zero out of 10 pain, or every once in a while, you have one out of 10 pain, and then I do a surgery on you, and you end up with one out of 10 pain every day, every step for the rest of your life, then we've done something bad. And so I am very, very cautious in kids, and I really want to make sure that they understand what they're getting into, that the parents need to understand everyone has to be on the same page to consider surgery. Thank you very much. Tracy, I'll turn it over to you for our next- Absolutely. Thank you. Okay, great. Up next is Caitlin Colosi. She's an orthopedic surgery and sports medicine physician assistant at Connecticut Children's Hospital, and she will be giving the talk on pediatric trauma. Thank you, Caitlin. All right, perfect. So I will bring my screen up so we can jump right in. I will also try to stay within the time constraints. I can be kind of long-winded, so I'll keep everything together. So like we just said, I work at Connecticut Children's. I do both orthopedics and sports medicine. So in terms of any of the foot and ankle trauma that I see, it's a little bit of a mix of things that come into clinic, and also things that we get called on for any kind of trauma call. I have no disclosures, but I do have a lot of patients that wanted to share a lot of images today about their own fractures and things that they've healed. I promise I do have female patients, but somehow I only had male patients that were there that wanted to share any of their pictures. So starting with the basics and some things that'll be kind of a common theme for everything, obviously with anything pediatric, there's going to be some things that go hand-in-hand with what would be treated similarly in the adult population. Any of our patients with closed FICEs will be treated with any kind of adult indications anyways, and there are some injuries that are so rare that I didn't include them because I didn't find that they're highly pertinent to practice. Salter-Harris classifications are going to be a common language for any kind of fracture. So for any kind of acute management and even ongoing management, it's kind of the bane of anyone's existence. I also find that in the pediatric population, it's important to talk about it right off the bat with patients and families. That way they kind of understand what kind of injury their kid is dealing with from the beginning. That way they know that the timeline of this fracture isn't going to be similar to that of something that maybe they had or anyone of their age. Knowing that it is going to be a growth plate injury too, comparison films will come into play, and as well as any kind of discussions of things down the line. Things we'll also touch on are kind of whether it's an apophysitis or an avulsion injury. I think for us, it's something that we're a little bit more comfortable seeing and understanding the difference between, but it's also a common second opinion or even a common consult that I see and knowing the difference is helpful. Something great about kids that we all know is that they heal fantastically. They have a wonderful remodel potential and they also heal very quickly, especially our younger kids. And in terms of healing really well, another good thing about kids is we want to make sure that we kind of protect them from any of the imaging, even though we want to continue to watch as things heal, we still want to make sure that we're appropriate in terms of imaging that we obtain. So I like to think of myself as kind of a radiation minimalist. And in terms of that, it's getting a CT scan. It's not easy to get a low dose CT in every setting. And I find that especially patients that are sent to us sometimes get the full gambit of imaging when it's not necessary. So a lot of times injuries out in adults, we would want to get a CT for children. It's not oftentimes indicated. So now going into fractures versus apophases, for us, especially in kind of our younger and adolescent populations, these are very, very common to see confused. And it's more so for us to know that we're going to see these as kind of a second opinion or again, a consult in the emergency department. A lot of times also in hospital systems that have primarily adult radiologists, I find these get read inappropriately or they have abnormal radiology reads. So a lot of times the physical exam is huge for these. The calcaneus is a big one. The fracture itself is incredibly rare in the pediatric population. And if you do see it, it's a lot of times in older kids, you can see it from an axial load injury, or unfortunately it's very commonly a part of a polytrauma or even an open fracture from a lawnmower injury. I've actually only seen it from lawnmower injuries, which I thought was just my black cloud of call shifts luck, but it turns out that it is actually factually a very common way to see this injury in kids. It'll be very obvious on exam because they won't be able to walk and they'll have significant swelling. And then on imaging, this is one of the fractures where a CT is often indicated. That way you can actually know the morphology of the injury and know whether or not surgery would be the move. If it is something that's going to go towards the articular surface or it is displaced, will oftentimes indicate for surgery at that point. And if not, you can often get away with just a short leg cast and allow them to be non-weight bearing. Apophysitis on the other hand is severs or calcaneal apophysitis. This is very, very common. We see severs all the time in clinic and especially because I do a lot of sports medicine too. This is huge during soccer season. And if you know kids these days too, soccer season is every season. So I guess severs season is also every single season. It is inflammation and pain caused by traction or stress, the calcaneal apophysis. A lot of times you will see these come in as chief complaint, calcaneal fracture. We've had these transferred before because they weren't able to push imaging to our hospital because we're a level one trauma center, which was highly unfortunate and also highly inappropriate. So this is something that oftentimes they won't have a mechanism of injury, but a lot of times for the athletes that present with this, they'll have a few different injuries that they'll bring up as maybe this is how it happened, but you'll be able to isolate the pain right over their calcaneal apophysis with a squeeze test. And a lot of the management is just symptomatic. They do great with activity modification, stretches and heel cups. Some of my athletes I'll also have do physical therapy because I think it's going to help them no matter what for any of their posterior chain. Next also, which is the fracture versus apophysitis. This is one that I think is less commonly known in terms of the apophysitis. In terms of the fracture, this is also a fracture that's very common though. So unlike the calcaneal fracture, we see fifth met fractures a ton with pediatric patients. Much like the adult population, it does have that abnormal interosseous blood supply. So knowing the exact anatomy of the fracture is also important. In terms of the Jones fracture, which falls in that watershed area of the bone, we will oftentimes indicate patients for surgery, but a lot of times they are also older patients. And if they do have a larger displacement of the fracture fragment. More commonly, I would say is the pseudo Jones fracture. And that also includes just the strict avulsion fracture, which occurs at the attachment of the peroneus brevis. This has a less likely chance of having the non-union, which is the risk of the Jones fractures, but fibrous unions are common. And I think talking about that with patients right off the bat is very important. That way they know that even if their fracture starts healing and looks a little bit abnormal, it's very common. And you can also protect their weight bearing and get them moving much, much quicker. Iceland's disease, which is the fifth met apophysitis. This is one that I think we more commonly see confused as being a fracture itself. Because on the imaging, you will see that widening of the chondroosseous junction. A lot of times they come in with that diagnosis of a fracture. And a lot of times it's kids who are like, I don't think I had an injury, but I had some foot pain. And urgent care told me I broke my foot. They'll have pain kind of directly on that area. You can see, I put an X-ray of one of my patients who had come in with that diagnosis. And on exam, he was walking fine. He had very distinct pain and a little bit of inflammation. And sometimes they'll even have some callus buildup because a lot of these kids are also athletes. And I find that it can be very frustrating inside of their cleats. Again, specifically in soccer athletes, because those are very unforgiving types of footwear. With these patients, a lot of the treatment is also symptomatic. So activity modification, stretching, and rest. Talus fractures. Even though I said I was going to try to avoid some of the more rare injuries, while these are rare, this is one of those red flag, do not miss fractures. This is something that if you hear about a pediatric talus fracture, it's something to look into very closely. So for that reason, it's another one that I would probably indicate for more advanced imaging, even in the emergency setting. Because of the blood supply of this bone, there is a very high risk of osteonecrosis, even for ones that are going to be non-displaced. So it's going to be a high energy injury. So a lot of times dorsiflexion from an MVA or an axial load fall from a great height. They'll have significant weight bearing pain or soft tissue injury. And you also have to evaluate for other injuries with these patients too. For the pediatric population, they do use the adult classification to actually take a look into the fracture pattern. But because a lot of times with the younger patients who have this injury, they might not have fully ossified bones of their foot and ankle joint. It can oftentimes be very appropriate to obtain an MRI to have a better idea of the fracture pattern. So type ones, which are the non-displaced, that would be the only type that you would really go right off the bat with non-operative management. However, operative for two through three or even attempting a closed reduction would be indicated, even with those early discussions about the risk of osteonecrosis is important. Like we talked about with the fifth metatarsal fractures, they are very, very common in kids, but also they heal most of the time very beautifully, which is fantastic. And I think patients and families love hearing that because sometimes, especially when you have multiple metatarsal fractures, the initial injury films can be a bit of a shock. And these, at least from my experience, are always the types of injuries where we get a call from the emergency department and they are incredibly shocked that we're not going to do much for it at first. The remodeling potential is fantastic. Knowing where the physis is will also help with these. So on the first met, you'll see approximately on two through five, it'll be distal. And because of that, we can actually allow for significant lateral and dorsal displacement of those fractures. Knowing if they're stable will really help too to kind of drive forward any management. But in terms of going forward with surgery, we tend to avoid it more often than not if it is something stable, but if it's causing significant disability, if it is, like I said, unstable, or if it's starting to cause problems because it's not healing and it's displaying evidence of a non-union down the line, that's when we'll indicate them. However, most of these patients do fantastic with a cast for three to six weeks. We can typically transition them into a boot once we start to see that early callus and then get them moving. These x-rays on the side are a patient of mine who actually had a stool fall on his foot. And as you can see, he fractured four out of five metatarsals. I actually believe his dad fell off the stool, but I said I would say just the stool to kind of maintain a little bit of their dignity, but I figured full disclosure would help to kind of get a better idea about the force that caused it. But the displacement laterally on his was able to be maintained in a cast. And after eight weeks, you can see that there was a lot of remodeling, significant callus to heal it, and over time, even down the line, that had completely remodeled, so it looked like nothing had happened. So he did wonderful. Toddler's fracture, I decided to throw in as well. Even though this is typically a tibial shaft fracture, it does extend oftentimes the distal tibial epiphysis. So oftentimes, especially on call, we will see positive ankle fracture, and it will be one of these. These are incredibly common in any of our patients younger than three years old. You'll see that kind of non-displaced spiral. You'll make sure, especially with these, that we have a pretty good history, but most of the times we won't because it'll be kids that will be at daycare because it'll be a very low energy injury as they kind of just twist through. For these, casting has really kind of fallen out of favor, so we'll either splint or do a tall cam boot for about three weeks, allowing them to kind of start moving on it, walking on it, or even crawling. So patients, again, do fantastic. Getting into the actual ankle. These are probably the ones that we see the most commonly, and we have to have much more discussions with patients and families about what to expect. For the lateral malleolar fractures, I decided to isolate just to kind of the distal fibula fracture on its own. A lot of times, these are low-energy injuries, and especially for kids, any kind of lateral ankle sprain, if the physis is open, you have to consider a Salter 1 injury of that distal fibula, and especially on exam, seeing if it is gonna be soft tissue pain versus actually being bony pain, and if there's any question, I would err on the side of treating it like it's a fracture. For patients that are a little bit older with any kind of distal fibula fracture, if they do have a closed distal tibial physis, evaluating for syndesmotic injury will also be big. For any classifications for these, they also tend to follow the adult classifications of the Danny Weber or Laggy Hansen. There is a more specific classification that ties those in with the Salter-Harris classifications, but I find that it's not as commonly used, but it can kind of help you a little bit more with bimalleolar fractures. I didn't include it for that reason, because like I said, it's less commonly used. For kids, a lot of these are going to be treated very similarly to adults, but again, you have a lot of leeway with non-operative management and kind of letting them walk on it right away. So the Salter ones and twos and kind of the Weber A or a stable Weber B, you know, a short leg cast or tall cam boot, weight bearing is tolerated from four to six weeks. So again, our pediatric patients love when they find out they just broke their fibula, because that means that they get to walk on it. And for them, that is huge. For some of our patients, we find out that they're a little bit bummed that they don't get a knee scooter though. For Salter three and four, you'll typically fix it. And then unstable B and C, that is also when you'll consider surgery. I threw in this rograts picture also, because when I Googled fibula fracture, because I didn't want to just put in clinical pictures, this is apparently what the commonly thought of fibula fracture is. And I think it's a little dramatic for management. Distal tibial, physio fractures, these are kind of the big ones for us and the ones that you want to focus on a little bit more. It's the third most common physio injury that you'll see after any phalangeal or distal radius. And for us especially, it's really pretty common in our athletes. So 58% of them will occur during athletics. The other is accounting for any twisting, low energy falls and NVAs. Something important seeing these patients, especially if you see them in the emergency department is knowing that they're probably going to come in, again, in cleats and in socks and in pads. So swelling will be pretty significant and also taking off any of that equipment will be a part of the process. I usually hope that EMS and anyone on the field leaves it on. So if you are someone providing kind of on-field management and you aren't going to be reducing this, or you don't want to treat this or mistake this for an ankle dislocation, just leave it, splint it, get it to the hospital as soon as you can. The reason that these are such a big deal to kind of pay attention to in adolescents and any of our younger athletes is because it has a high complication risk. We like to joke that the distal radius, for example, can take a hit. It can be broken and it can be reduced and it can be very difficult to reduce too. But even with all the shearing forces, typically does pretty well. Distal tibia is not as forgiving. It has a high risk of any premature phalangeal arrest or even phalangeal bar formation, which can then down the line lead to any angular deformity or any articular incongruity if it's missed early on. So again, because of that, these are fractures where it may be indicated to get advanced imaging or like a CT down the line. For these also, Salter-Harris classifications are going to be the most common to look at. One in five are very, very rarely seen. It's like less than 1%. That other classification that I had noted, that can sometimes come into play here, kind of incorporating the Laggy-Hanson and also using that to look into that in comparison with the Salter-Harris. It can be good in terms of thinking about any reduction techniques, but a lot of the time you can kind of determine that based on the fracture and the force that caused it. Another subset of these are going to be transitional fractures, which occur as that vise is closing down, which we'll also go into. Most commonly, you'll see a Salter II. A lot of times this will be reported as a Salter I, I have found, because people miss the smaller fragment, which we call the Thurston-Holland fragment. I do have some Salter II distal tibia x-rays that'll be on the next slide too, but because this is most common, you'll see this in about 60% of fractures or 60% of these distal tibial fractures. And then the rest of them will typically be a III or a IV. Those ones are the ones that you look into a little bit more closely because they do have a higher risk of growth arrest and because they do go into the joint. Those are also commonly seen as isolated medial malleolar fractures. And for us, they are most commonly are trampoline park injuries. So as much as we joke that trampoline parks are kind of keeping us in business, it is not great for the vises for the kids. So it's a good and a bad thing. For any of these fractures, you're going to want to attempt like a closed reduction and then a cast or a splint application in the emergency setting. For us, we find that any kind of adequate sedation is going to be key for these. This isn't something that I would attempt in the office if it does come in. And I, in our emergency department, they do tend to do ketamine sedations. If they do have ketamine and pro-false sedations, they're also good, but it's harder to come by. And typically in any of the teaching hospitals too, they aren't really allowed to do them. So it's not as easy to get that. But the biggest key to this is also making sure that you can get any kind of relaxation of the gastroc soleus. So I will do kind of a modified Quigley maneuver where for any of these, positioning will help. You don't have to be the strongest person to reduce these, but limiting the amount of reduction maneuvers that you do to limit that shearing is key. So I do like 90-90 at the hip and the knee to relax. That way you can pull the fracture where you need it to be. So for those SALT-R2 patients and children less than 10, you can have some mild residual angulation. It'll remodel fantastically, but you still want to get as anatomic as possible. You can do a shorter long leg cast for about three to four weeks, and then sometimes progress weight bearing, switch them into a boot. But for three and four, getting a better, oh my gosh, a better idea of the interarticular displacement is going to be key because anything greater than two millimeters will require that surgical intervention. For any of these patients anyways, getting that initial reduction is going to be key. That way you can kind of decrease any skin tinting and any damage to the soft tissue. This is a case study of a patient that I had treated. He was an 11-year-old who was brought in via AMS after a lacrosse injury on turf, which turf, much like trampoline parks, has also been a very common injury generator for us. The actual reported injury for him was just an inversion ankle injury where based on his initial films, that's very clearly not the case. He underwent a closed reduction and sedation after serial casting and continued monitoring. And of course, significant amounts of patient and family education right from the very initial visit. He was able to return to sport. He then came back after about six months reporting some swelling to his medial ankle joint. He was coming back at that point anyways because we were monitoring his physis. For any of these patients and any kind of physio injury, we will, after that clearance point, monitor them every three months just to continue to make sure that we're watching for any early physio closure until you have at least six months without any change. So after a six month point, this is how his imaging looked. I thought this was an interesting case because even if you can get an adequate sedation and adequate reduction for these, especially the Salter IIs, there's a significant risk of having periosteal imposition. It can sometimes block your reduction, but even if it does not, it can still interfere with the way that the physis grows. So with him, you can see on both the imaging as well as the little slice of the CT that he did have the periosteal imposition when that kind of changed the way that his physis started to develop. He did have a physio bar that I didn't show because it was very, very small on another slice of the CT scan, but over time he was able to actually grow past this and grow through his physio bar. So he's back with full clearance and no difficulties returning to sport. But for any of these patients, the importance of any surveillance of the physis and kind of laying that information off from the very, very early visits is very important. The transitional fractures are gonna be in your older patients. So the tallow is going to happen probably in the oldest of our pediatric population. So our much older adolescent patients. It occurs when the central medial portion of the distal tibial physis are starting to fuse. So even though this is going to be a physio injury, and we know that the risk is that the physis is going to close after this, the physis is going to close anyways. So it's much less of a true complication in this type of injury. So it's a SALT-3 of the anterolateral tibial epiphysis, and you'll see a large external rotation injury and the ATF actually can pull it off. So it's kind of an avulsion type through that fracture. We will get CTs on these again, that way we can have a better idea of what's going on with the intra-articular component. That way, if it is a larger displacement, we'll indicate surgery for these patients. The other transitional fracture is a triplane fracture. These are a little bit more complex because they occur in patients that are a little bit younger, and you'll see the fracture going through three different planes that disrupts the tibial plafon. So through the coronal plane, it'll go through the posterior metaphysis, sagittal through the epiphysis, and then transverse through the physis. I have a few cuts from a CT as well as an X-ray of a recent triplane fracture that we had that came through our emergency department and then eventually had surgery because you can see there's a large intra-articular gap on the CT that we wanted to close down. These are usually a supination external rotation injury, and because of this also, we know that based on the fracture force, the growth plate's also probably going to close down, but again, for these patients, it's almost expected. I typically try to describe this to the patient as if the fracture force kind of hits like a brick wall when it hits the place where the physis has eventually closed down, and that's why we see these very abnormal fracture patterns. These, again, are great fractures to get CTs for so we can have a better idea about the alignment. That way, even if we do attempt a close reduction, if we have an alignment that's not acceptable, we can then indicate them for surgery. So some takeaways I think can be used more in clinical practice. I think any of our pediatric and adolescent patients are very, very driven, and especially for me, since I work in sports, I find that they want to have an end goal and a timeline, and I find that teaching right off the bat what to expect and even showing them what to expect is very helpful. So a few resources, again, like I said, I have no disclosures. This is just me and all of our different providers in our practice kind of pulling from different sources, but PASNA and OrthoKids has a lot of great handouts, and we give them to a lot of patients and families because sometimes if grandparents come to the appointments, they're not as great at handing on information, and I find a lot of times with these growth plate fractures especially, making sure that the point is understood and it's established and it's broken down into more easily understood languages is very important. So that helps. A lot of pediatric hospitals and institutions already have some accessible handouts that are available online, and then there's another textbook that we have recently had, which is just the Fracture Healing in Children. It has a lot of different pictures and x-rays at different stages, so especially for those fractures that look a little bit more abnormal and you kind of want to prove to patients and families that they will remodel, having actual tangible proof of x-rays and images that have remodeled in the past is great to have on hand. Something that is also fantastic for our PTs and any of our trainers and anyone else here too is it's not just going to be our PAs, NPs, and any of our physicians who are managing fractures. There's a lot of other things that our patients can do, especially in the pediatric population. Cast and boots are not going to be entirely limiting, and I found that especially with our athletic population, they want to do more and they want to limit muscle atrophy. So starting right off the bat, even just encouraging kids to use crutches. I know that the youngest recommended age is seven, but even just training them to get moving right away will encourage them to get moving sooner rather than later. Understanding their timelines will help them be more driven to move forward. And then even that return to sport and return to play can be discussed right off the bat. So you can see one of our kids who's in a cast is actually at physical therapy there to start working on some quad and some hamstring strength. He's actually doing some BFR as well, which we're working on researching a little bit in our clinic, but we have found that even just having kind of the mental mindset of knowing that they can do more helps them get back. And even just getting on the field helps. Modifying anything for activities, especially for athletes is fantastic. For example, like I said, for our baseball athletes, throwing progressions from a tee and even just doing basic batting drills from a tee really helps them get back into everything. So the best part about working in PEDS is having those driven patient population. And this is, again, one of my patients who wanted to share this picture because his biggest takeaway from his injury and his whole projects that led into, after his ankle fracture was that a minor setback made for a major comeback. So even though pediatric foot and ankle trauma is very common there's a lot of ways to get these patients through it and make sure that they feel comfortable and feel safe with all the care. So thank you so much. I'm glad I finally got those slides working. So thank you for bearing with me. Thank you, Caitlin. That was great. It doesn't look like we have any questions for that talk. So I'll give it away to Dr. King. All right. So now we have Dr. Ishmael. He is a pediatric orthopedic surgeon at Shriners for Children in Philadelphia. His interests include spine surgery as well as lower extremity pathology. And he's going to talk to us about the tight heel cord. I'll turn it over to you, Dr. Ishmael. Can you guys see my slides? Yes, sir. Great. So, hey everybody. Nice to, thank you so much for inviting me. My name is Terry Ishmael and I'm a pediatric orthopedic surgeon at Shriners Hospital for Children in Philadelphia. You know, we're going to talk a little bit about conditions associated with the tight heel cord. I do not have any disclosures. We're going to go through the evaluation presentation and management of calcaneal apoptositis otherwise known as Severs disease as well as pediopathic toe locking. Severs disease is probably one of the, if not the most common causes of heel pain in children between eight and 15 years of age. It's especially common in kids participating in sports. And as we heard a little earlier, particularly common in kids self-participating in soccer. I won't belabor Severs too much because we heard about it a little bit before, but its incidence is about 3.7 per thousand patients and typically has an insidious onset. It's not associated with a specific traumatic event. History and physical is key. You know, this is a clinical diagnosis. So usually we will not get imaging for this once the story fits. As I mentioned earlier, the onset is typically insidious. There's typically no major trauma and usually these kids are very active. The kind of pathognomonic examination finding is the calcaneal squeeze test, where you apply pressure on the medial lateral portion of the heel and this will incite pain. If you were to get images, typically we get a bilateral and oblique views of the foot and ankle. These would be weight bearing. We may consider getting contralateral ankle films for comparison. You may see sclerosis or fragmentation of the calcaneal apophysis. This may be present, but is not necessarily diagnostic. Treatment is usually pretty straightforward. It's a combination of rest, physical therapy, orthoses and NSAIDs. If you use any of these modalities in isolation, typically they'll be successful, but there is some suggestion in the literature that when used in combination, you can lessen the duration of symptoms. Pretty quick and easy overdue receivers. I think we talked about it a little bit before. Usually it's pretty straightforward and resolves pretty quickly. So we'll talk a little bit more about pediopathic co-walking. What is co-walking? So it's an abnormal gait pattern. The child would typically walk in the balls of their feet without any heel strike. It's very common. It often presents before two years of age and up to around 5% of toddlers may present with it. Pediopathic co-walking itself is a diagnosis of exclusion. History and physical examination key. There are some really important historical findings that we have to make sure that we ask about to ensure that there's no other really serious pathology that we could be missing. We wanna ask about the birth history, whether or not the child has been beating their motor milestones. Is the toe walking getting worse? Has there been any treatment and has it been successful? Are there any issues with potty training? Is this may signify a spinal dystropism? Is there any leg or back pain, which again can be associated with spinal dystropism? And is the child autistic? And also, does the toe walking change during the day or is there abnormal positioning of the pelvic angulation? And is there a family history? Physical examination findings are really important. There's some really key things to look for. You may wanna address the child, or at least put them in the gown and kind of take a look at them from head to toe. We will start with evaluating their gait and they'll take a look at whether or not they're actually able to get their genomes down. We do examine them, kind of get an idea of their range of motion. And then also, perform a silver stool test to figure out whether or not the gastrocnemius is involved in isolation or whether or not the gastrocnemius and soleus muscles are involved. Is there a calf hypertrophy or proximal muscle weakness? Is there a gout sign? Are these children really weak? Is there any spasticity? Is it unilateral? I think unilateral is really important because there are other pathology that can be involved, such as a limb-like discrepancy and or hip dislocations. And some other things to look at as well. So once we've established a diagnosis of pediatric toe locking, what do we do? We do know the majority of these children will have resolution of their symptoms or their toe locking by the time they reach about five years of age. Those children with normal range of motion typically will perform bracing and physical therapy. Those with limited range of motion so that they are unable to dorsiflex past negative 10 degrees. You know, we may consider serial casting and or surgery with bracing and physical therapy to follow. There has been some consideration of use of Botox in the past with casting, but I think we're in general moving away from that. I do know some pediatric rehab doctors do use it, but there is some data to suggest that there are really no difference in outcomes when adding Botox. These are, you know, some of the things that we do. You know, casting, again, is very common. I like to put them on with the child prone and being distracted by our child life therapist or parents. Typically we use fiberglass and try to stretch as much as we can with each progressive cast. Usually I change them once a week. If it's unsuccessful or if this is something a little bit different from idiopathic co-walking, we may consider surgery, kind of dependent on whether or not you have a gastroc contracture in isolation or whether or not the gastrocs and soleus are involved. And typically we'll perform one of these types of lengthenings followed by a period of casting and bracing. Typically I put them in a AFO for probably six weeks to three months, depending on how strong they are after they come out of the cast and continue with physical therapy. Oftentimes we'll consider putting them in brace overnight to kind of maintain what we've gained. So that's it, pretty short and dirty. Any questions? Any questions so far, maybe at the discussion part, I'll turn it back over to you, Tracy. All right, then, our last session is, we'll be talking about a tight heel cord from a physical therapist approach so I'll introduce Dr. Lisa Selby Silverstein. She's a professor at Newman University. She's a physical therapist, and a neurological clinical specialist with a PhD in pediatric physical therapy. Thank you so much. Hi, thanks for having me. Um, my background is a little bit different than a lot of you, because, well I've, I've been treating for around 40 over 40 years and I did my doctoral research related to this topic of pediatric feet, and the effects of orthotics on So I look at things very much from a gate and a neurodevelopmental perspective as well as the orthopedic. So with respect to tight heel cords, PT management involves more than one might think. Tight heel cords may be preventable, they're not simple to treat, and they can have profound effects on biomechanics and function. Okay. So, I'm going to talk a little bit about what I mean by tight heel cords. So, I'm going to talk a little bit about what I mean by tight heel cords. So, I'm going to talk a little bit about what I mean by tight heel cords. So, tight heel cords can result in functional concerns or sequelae, the first being as, as people have been discussing is Severs injury with tension from the heel cord, placing, inflaming the growth plate, and sometimes even resulting in fracture of the growth plate, which again, doesn't necessarily show up well on the imaging, so is made by a clinical diagnosis. The second one with a tight heel cord you'll see toe walking. The big issue there, a couple years, a number of years ago there was a big conversation, I was very active in the Interdisciplinary Gait Society which had a lot of orthopedists and a lot of other people involved in gait. And there was a lot of discussion about is toe walking really a problem. The big problem that it comes down to is the vertical bounce so in a child, you're one of the goals of gait is to keep your head stable, and so that you can take in your environment, and when you're bouncing up and down. Beside that you look weird. You're also not able to take in your environment. The third thing is that, as our first speaker was discussing is a tight heel cord is often associated with over pronation, and also can lead to compensations up the kinetic chain during stance phase. And so you can see knee hyperextension, you can see, and as we know, flat foot is a triplanar motion. And so it not only has the flexion component but the internal rotation adduction, which is why you may see some proximal effects. With these different things you may see some decrease in speed of gait and decreased balance associated with these problems. So, treatment for severs I'll go into first is to stop the pain and heal the growth plate. Interestingly, we did a survey, mainly through the APTA of how long the children that they saw with severs how long people thought they had had severs before they had been seen by a physician or a therapist to address the pain, and by and large it was a long So I initiated this study because I was concerned that kids would come to me and their parents would say oh I just, he's saying his heels hurt but I think he's just really trying to get out of karate, or something like that and then he's pointing exactly the site and having positive signs and it's, it was, I felt bad for these kids sometimes they're, you know, limping off the fields before their families are willing to realize that they actually have a problem. So the first thing is treatment of severs and the potential sequelae of the tight heel cord can be done in steps. So one of the first things that I do is add heel lifts. I have like Spanko in my office and I just layer up the Spanko under the heel and roll into the arch and tape it together, do something quick so that they have something to offload the tension in on of the heel cord. And then I work on active range of motion into stretching this is a kid doing, doing a stretch that also hit some other muscles. So it's not just a one thing. I like to do taping over socks this is, I know this is a crazy thing that probably most people don't do but it actually works really great with kids because when you want to take them off you just take the sock off and they don't have any of the skin And this is, I use this as a way to see whether supporting the arch is going to manage the pain. So, also there's always the resting neutral night splint, anti-inflammatories as were discussed, foot orthoses, and if the pain doesn't resolve, there's been times when we've had to go to immobilization. And then we'd like to transition them to arch support afterwards, so that they don't continue to develop these tight heel cords. Wait a second, my thing is not there we go. So, um, I wanted to introduce these because instead of the cast boot, as, as our last speaker was just saying our kids like to stay active. And what's really nice is that we make these aquaplast ankle foot orthoses that are bivalve immobilizers, and they go into sneakers, so they're a little larger sneakers, but this is if the kid needs to be immobilized. And you can see here that the gait is pretty normal compared to having to wear a cast boot. And so that's just a regular they're really easy to make just a regular low temperature plastic. We just charge for the plastic and the and the time to make that. It's not an orthotist made thing it's a therapist made thing. And I've had kids play sports with these, you know, like baseball, etc. With different foot orthoses options there's different over the counter options, and also some of the labs are making will make custom lab custom orthoses as well as some of the, the other places if if you feel like you need them facility makes So the treatment goals. So that so that's basically the thing with with sievers. The only other thing is that if you do have to go to a mobilization, I learned this the hard way with my own kid, who was the first person who got me involved in sievers and I lived with it and then my nephew got it and so I lived with it again, um, is that after you immobilize them you have to do strengthening so the PT forgot to do strengthening and watched hit my son, take you know no more pain, he's going to run around the bases and realizing he has no push off because he's been immobilized for a week so yes we do have to do strengthening after we immobilize. With respect to treatment goals related to idiopathic toe walking the Cincinnati Children's Care Guide is a really nice document. They talk about for toe walking having ankle dorsiflexion with the knee extended greater than or equal to 10 degrees measured in subtalar neutral, and no reports of unintentional toe walking. So, I generalize these goals to children with neuromotor toe walking problems also. So, of course, you guys are not the audience to tell that there's that all the muscles that cross the ankle also cross the subtalar joint, since nothing attaches to none of the muscles that are attached to the talus. And so we just have to remember that their effects are not just at the ankle. They're going to be affecting the subtalar joint and during gait, the posterior tip is controlling the hind foot pronation just after heel strike, and then the gastroc and soleus are controlling the dorsiflexion through stance phase eccentrically. And then in terminal stance we have the deep muscles, posterior tip, flexor hallicus longus and flexor digitorum longus turning on to control the roll off after heel off. And so what leads to these tight heel cords is basically use patterns. So the use patterns, the two use patterns that can lead to the tight heel cords are idiopathic toe walking or over pronation. And I would say that they're preventable, and that's why I advocate giving children arch support, so that we can potentially limit these tight heel cords from happening. Children may experience toe walk and may also over pronate for sensory reasons. So if they have decreased proprioception and vestibular input, then often the toe-toe gait gives them that increased sensory input, and pronation may help them seek the floor if they're having either balance concerns or sensory need for increased input. They may have sensory hypersensitivity or tactile defensiveness, so their perceiving input as noxious or too much can result in a toe-toe gait pattern. Growth spurts, plantar flexion spasticity, poor motor control and timing of dorsiflexion during gait, and abnormal weight shifting can all play a role in the development of these problems. It's important to recognize that because the foot is right on the ground, it's directly affected by the ground reaction force, and so the diagonal weight shifts that go up and down and diagonal are important during gait to develop normal foot movement. So working on balance and diagonal weight shifting is really important for optimizing foot and ankle function, and that is because the ground reaction force is made up primarily of weight from the body. It's the force on the ground equal and opposite to the force applied to the ground, and that's primarily from our weight, so weight shifting is what affects that, and then the torque about the ankle is the balance between what happens with the ground reaction force and the muscle activity opposing it, and so that's what determines what's happening at each of our joints. And as I said before, the feet are right on the ground, so they're very affected by the ground reaction force. So the PT plantar care depends on the cause of the inadequate dorsiflexion, so if it's tight plantar flexors, tight muscles, we want to know which muscle is happening, we want to stretch. I like to encourage active stretching, mainly because I'm concerned about severs. I don't want to overstretch a kid that has a growth plate, and so a lot of times we can get some good stretching actively. Night splitting. The DOF09 has continuous improvement straps, or we go with serial casting for somebody who, again, as Dr. Ishmael was pointing out, for significant cases of tightness. If they have spasticity, we like to use functional electrical stimulation to activate the dorsiflexors and get reflex inhibition to the plantar flexors. If they have joint limitations, checking that to see if we can do some joint mobilization and get that moving. If they have weak or inactive dorsiflexors, we go with the strengthening, electrical stim, functional electrical stim, ankle foot orthoses to compensate or elicit dorsiflexion balance responses, like we pull them back onto their heels to get them to dorsiflex as a balance response. If they have poor timing of dorsiflexion, really our main thing is functional electrical stim or compensation through an AFO. And then if they have weight shifting problems, like they're not diagonally weight shifting, then we need to work on that and work on strengthening whatever's needed to optimize that single support phase of gait and get them to laterally diagonally weight shift, which is what's going to get them going over to the lateral border of their foot to get that supination for push off. And if they have sensory issues, sensory bombardment to increase their input and improve their awareness or work on desensitization. So this is an over-the-counter cascade fast fit jumpstart, which sometimes can be used for night splints. The only caution I have about night splints is that if you're going to, you have to figure out whether your gastroc or your soleus is tight or other muscles. And if it is your gastroc, you want to stretch it with the knee extended. And that is only going to happen if you put the person in prone or have a knee immobilizer on them. Nobody wants to sleep with a knee immobilizer. So they're not really, I don't find they're useful if it's a gastroc tightness. I do find they're useful for periods of time. So for like 30 minutes while they're watching TV or something like that, but not necessarily sleeping. But if it's a soleus, then maybe it would be helpful for sleeping. DOP09 is this new brace that has come out that has these straps and it's been offered as an alternative to serial casting. I haven't seen any research on it. I don't know if Dr. Ishmael has tried it. I haven't tried it. My only concern about it is that it's an AFO. It's not a walking AFO and if the kid needs an AFO later, you've spent their money on this device and then they can't get an AFO. This is a study we did a long time ago, looking at bivalve serial casting for an athlete and showing that we were able to, with this positioning, with 30 minutes a day, increase the heel cord length and that it was dynamically used and there wasn't any increase in pronation, compensatory pronation during gait. So to get repeated heel strikes, you have to have practice. And if the kid has a neuromotor problem, as I was discussing, functional electrical stimulators are gonna activate those dorsiflexors and get them relearning how to dorsiflex or learning for the first time. Custom AFOs are often needed to maintain the patterns. You can go with the hinged or if they're crouching, you have to go with something that's gonna also stop the dorsiflexion. So a dorsiflexion assist, dorsiflexion stop. And then lastly, goals related to the overpronation. So lengthening the tight heel cords to enable adequate passive range of motion for good foot alignment in foot orthoses without compensatory pronation and preventing tight heel cord development by minimizing the time the children function with overpronation. So that's by using foot orthoses or arch supports. Optimizing lateral diagonal weight shift patterns during gait to promote more normal foot use patterns and strengthening foot intrinsics, hip abductors, external rotators and extensors. So as our first speaker was discussing, all kids pronate. And so pronation is not always a problem. So I always was asked how much, this is what got me into my research initially that I did my PhD on is when do I do orthotics and when do I not? When I, back in the 19, well, I won't even tell you when, but back when I did my dissertation, if you were a podiatrist, you ordered orthotics and if you were an orthopedist, you didn't. And I was, as a PT, I was like, I really don't care. I just wanna know what the science behind this is. And I'm really not caring about the politics. And so I had to establish some ideas with myself. And so I identified this Valmasi criteria, which is a rule of thumb. And it's that the heel aversion relative to vertical was greater than seven minus the child's age in that they should start to come up to vertical around seven years old. That's really gushy. And so the other thing that I use is because I understand the relationship between the center of mass displacement and development of the arch is if they can diagonally weight shift and they're within those Valmasi criteria, then I don't give them orthotics or I may work on the weight shifting and the foot action activity and or go with orthotics if those things are not gonna be possible like in a child with downs or some other challenges. So we have to remember that tight heel cords are often present with pes planus. So we wanna evaluate that and stretch that out. So what is evidence that the gastroc soleus muscle is related to pronation and supination heel alignment? I was happy to hear our first speaker talk about those tight heel cords in pronation. I did a study in 19, well, it was published in 1997 where we did bone pins into cadavers. And we looked at the length of the gastroc, the two heads of the gastroc. And with the foot in inversion, neutral and eversion. And my initial hypothesis was that neutral would be the longest position of the gastroc and that inversion and eversion would both be shorter. And I just thought they would both be equal. And that's what these little balloons on the left here are these are gastrocs. And these are my theory with the cup of the heel. And then if it was in or out that would bring the distal attachment more proximal. What we found was interesting. We found that neutral as we expected was the longest position of the gastroc for the medial and lateral head. But then eversion was slightly shorter and then shortest was inversion. And that's for the subtalar joint. And of course with the ankle, dorsiflexion is the longest position. Neutral is in the middle and plantar flexion is the shortest. So you can see where the combination of those motions are gonna result in how long the muscle is. And that really explains some of the compensations that you see. Where if you have a little bit of tightness like in an athlete, you might get pronation or early heel off. Whereas if you have tight spasticity, you may get toe walking or you may, if the person wants to keep their heels on the ground, they may severely evert. So it also has implications for treatment. And so that if you wanna stretch a heel cord, muscle length is longest with neutral subtalar joint and ankle dorsiflexion. And of course with the knee extended. And it's shortest with subtalar inversion, ankle plantar flexion and knee flexion. So that's the best position for stretching in serial casting as well as actively or passively. So non-weight-bearing stretching, I always tell the kids big toe leads, big toes in charge so that they'll avoid the pronation. And then general weight-bearing stretches can be done avoiding pronation. So we have 26 bones in the foot. The foot is more likely to deform during a stretch of a heel cord than the heel cord is to stretch. And so I really like them to have foot support when they are stretching their heel cords so that, and I encourage them to avoid toe out while stretching because the toe out and not having arch support is gonna make them pronate rather than stretching their heel cords. I try to avoid passive heel cord stretching to help avoid severs unless the child's unable to actively dorsiflex. And again, when we do do passive stretching with a strap or manually, the big toe leads. So lastly, I just wanna mention that infants and children typically move in ways that stretch, strengthen, provide sensory input to develop foot, ankle and toe awareness. So while bracing or casting might be needed, children need to spend time barefoot. And there's a lot of functions as you can see the child crawling. There's a lot of functions that happen that aren't with 90 degrees of ankle, with an ankle neutral position. So we have to allow for that. These are my references, but I just wanna, if I have time, I just wanna quickly just mention that these key recommendations from the Cincinnati Children's Care Guide are really nice. Early identification and treatment of children with idiopathic toe walking is needed to prevent adaptive shortening of gastroc and the development of persistent abnormalities in gait and balance. The efficacy of conservative treatment of children with ITW is dependent on the amount of gastroc and soleus contracture, the percentage of time spent toe walking and the age of the child at initial eval. Older children are more likely to have a significant gastroc contracture and might not respond with equal success to conservative treatment measures as the younger child with ITW. Ankle dorsiflexion passive range of motion may not correlate with the amount of ankle dorsiflexion in gait and use of an articulated AFO to encourage heel strike and normal first, second and third rockers recommended in children who continue to toe walk despite having adequate ankle dorsiflexion passive range of motion. After weaning the child from use of the articulated AFO, a foot orthotic may be necessary to improve foot alignment in gait and to prevent recurrence of gastroc pneumias and or soleus contracture. And Botox injections to the gastroc and soleus may improve ankle dorsiflexion, passive range of motion and gait kinematics and may be used in conjunction with PT treatments, serial casting and or AFOs. But like Dr. Ishmael said, there's been a pretty recent study that said it didn't make a huge difference. So thank you for your attention. Hi, doctor. Thank you. We have one question if you don't mind answering. Sure. I'm trying to stop sharing my screen. Thanks. You're fine. There's two. So the first one is, when do you call failure a physio and advocate intervention? Okay. So I guess when you're saying intervention, you're not thinking of physio as intervention. So I think of physical therapy as intervention, but I think you're meaning surgery. Is that what you're meaning? So I'm just reading. So I'm assuming they meant surgical intervention. Yes, ma'am. Right. So I agree with our first presenter that I try to avoid the surgeries. I mean, I really try to, I think that there's, it's the more rare cases of these kinds of patients that are gonna need the surgeries. I don't know if Dr. Ishmael and Dr. Zaid have a different view on that, but I have had, I do have a difference with Dr. Zaid with respect to orthotics. I've had really good success with firmer orthotics. I think like when you're gonna do surgery to correct a forefoot varus, if I can support that during, with an orthosis, that position, while they're wearing the orthotic, I think it does make a difference. And there is some evidence that orthotics can help prevent the progression. Maybe not, it's not gonna be surgery, but it can help prevent the progression. That Wenger study was interesting because I actually had to review that Wenger study for my comps, for my PhD. And it was, in that study they did, they looked for a change with respect to the x-rays when they wore orthotics, when they took the orthotic off. So they wanted to see if using an orthotic was going to have an effect when the orthotic was not on. And I don't think that that's really what orthotics are intended to do. They're not gonna, they're not surgery. They're not gonna change the person's foot itself. Maybe over time it could, like I said, prevent things, but they're really just holding a position and supporting a posture while the orthotic's on. So I don't know if anybody else has a view on when the PT has gone too far, but I mean, it hasn't gone far enough and you need surgery. I think pain obviously is a big one. I don't know, Dr. Zide, I think gave pretty good guidelines for that. I don't know if you wanna answer that question. Dr. Zide, do you have anything to add? Or I have another question that I think is directed to Dr. Zide. You're on the spot, sir. I know, I think that was a nice answer. I think that sperm orthotics certainly are more powerful than soft orthotics. My issue in general with sperm orthotics is that I've also seen them cause pain. And then what ends up happening in my experience is a lot of these, first of all, the custom orthotics to kids versus adults is different, right, because you're getting custom orthotics, they're growing, they're expensive. And then a lot of the time these kids get told, you need this orthotic, you need this orthotic, and now they're just sort of living with this uncomfortable thing that they don't really like in their shoe. And they only seem, they don't necessarily see their provider or their physical therapist for the rest of their life. And now they've had this thing in for five years that they really don't like and they think they're not allowed to take it out. And so I just find the soft orthotics are just much less frustrating for them over time. But I understand your point totally. But yeah, I'm happy to answer any other questions. And we have just one more question, and this is something that we didn't touch on, but we had, do you have, well, they're asking about an algorithm for Kohler's disease. How do you approach it? It actually might be a better question for Terry. Kohler's is a pretty, there's really nothing to do. It's, I don't, most of the time I don't see kids quite that young and Kohler's, at least as I understand it, is a pretty self-limited thing. There is some question as to whether or not it's something called Miller-Weiss disease in adults. But that connection has never actually been made. And so in general, there's nothing to do. Watchful waiting, if it's painful, I think sometimes it'll immobilize them, but I don't think there's too much else to it, but I'd be happy to have Terry jump in. And I'm really glad to see you, Terry. Good to see you, John. I think that, I mean, again, you kind of knocked it out of the park with your explanation that there really isn't a whole lot to do. It's just really expectant and symptomatic control. Oftentimes we'll put them in a boot, if necessary, if the boot doesn't work, then put them in a cast and really shut them down for a couple of weeks. But usually symptoms will nearly, in the majority of the cases, resolve within like three, four weeks. And then if you feel inclined, you can follow them radiographically and make sure that the changes have resolved. But again, there really isn't a whole lot to do for it. Can I go back to something Dr. Zeid had said about the orthotics, that I just want to put in a plug that a lot of orthotics are dispensed and then they're not given PT along with it to make sure that they have the heel cord range of motion to tolerate the orthotic. So if they mold an orthotic to somebody's arch and then they don't have the range to allow the person to have that, maintain that arch, like you were talking about the biomechanics of pushing the talus down and the vicular down into the arch. So they have to stretch out the heel cord along with that. So that's just important. I think a lot of times people just, I have a lot of people come in with orthotics that don't work and it's really not the orthotic that's a problem, it's that they don't have the range. Any other questions? All right, well, we went over a little bit, but I thank everybody for the great talks and attending. And I guess with that, have a good night. Thank you.

Pediatric Foot and Ankle Pathology

fractures and apophysis

common foot and ankle fractures in children

treatment options

imaging considerations

management

calcaneal fractures

fifth metatarsal fractures

talus fractures

ankle fractures

appropriate diagnosis

growth plate injuries

patient goals and expectations