New flatfoot data rekindle debate over role of obesity ...€¦ · In addition, gait pathomechanics may be asymmetrical in patients with CMT, she added, with some patients having

february 2014

New flatfoot data rekindle debate over role of obesity

Strength training improvesfunction in children with CP

PLUS:• Long-term clubfoot outcomes

• Improving Down syndrome gait

• Variable ankle function in CMT

• Meniscal tear repairability

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lowerextremityreview.com 02.14 3

:

news

features

4Ponseti method surpasses surgeryfor long-term clubfoot outcomesBut both groups fall short of controlsBy Samantha Rosenblum

5 Ankle dorsiflexion patterns varyin Charcot-Marie-Tooth disease Data support case-by-case approachBy Larry Hand

6 Ankle weights improve walking in children with Down syndrome Load may help engage plantar flexorsBy Larry Hand

7 In youth athletes, repair aftermeniscal injury poses challengeObesity, gender affect tear complexityBy P.K. Daniel

9New flatfoot data rekindle debate over role of obesityAustralian researchers found no correlation between body mass index andprevalence of pediatric flatfoot, but used a different methodology thanprevious studies that reached an opposite conclusion. The conflictingresults have revitalized the ongoing debate on this topic.By Cary Groner

15 Strength training improvesfunction in children with CPResearch suggests strength training can improve gait and function inchildren with cerebral palsy. But to be successful, experts say, the trainingneeds to be part of a multifaceted rehabilitation program that accounts formore than the physical limitations imposed by the disease. By Shalmali Pal

From the editor:Shaping the future

One of the most rewarding aspects of pediatric lowerextremity care is the knowledge that early interven-tion can have a positive effect on a child’s entire adultlife—a theme that is repeated throughout this specialpublication dedicated to lower extremity pediatrics.

In some cases, the upside of early intervention isreadily apparent. For example, new research demon-strates that children with clubfoot who are treatedwith the Ponseti method have significantly better func-tional outcomes as adults than those treated with sur-

gery. Research also suggests that children with meniscal tears who aretreated within three months of injury are more likely to have tears that canbe repaired rather than removed, thus significantly reducing the risk of earlyonset knee osteoarthritis.

In other cases, the picture is less clear. Experts have yet to reach a consen-sus as to whether early intervention in children with flexible flatfoot mightspare those children from more serious issues as adults—a debate that becomes even more complicated when the issue of childhood obesity isadded to the mix. Early intervention in a child with Charcot-Marie-Tooth(CMT) disease can positively affect that child’s gait pattern for years to come,but only if the treating clinician is aware that not all gait impairments in pa-tients with CMT are the same.

Improving a child’s pain and function for now is a worthwhile goal. Improvinga child’s pain and function for a lifetime is even better. That’s why we’ve cre-ated LER: Pediatrics, a quarterly publication dedicated to pediatric lower ex-tremity care and filled with the type of evidence-based information you needfor both short- and long-term clinical success in treating your littlest patients.Let us know what you think.

Jordana Bieze Foster, Editor

istockphoto.com #11596239

4 02.14 ler: pediatrics

Ponseti method surpasses surgeryfor long-term clubfoot outcomes But both groups fall short of controlsBy Samantha Rosenblum

Children treated for clubfoot with the Pon-seti method have less pain and fewer gaitimpairments as adults than those treatedwith surgery, according to research fromShriners Hospital for Children in Chicago.

In 42 adults aged between 19 and 35years who were treated for clubfoot as in-fants (24 surgically, 18 using the Ponsetimethod) between 1983 and 1987, re-searchers compared the long-term resultsof each procedure in terms of foot function,foot biomechanics, and quality of life; theyalso compared the clubfoot patients to acontrol group of individuals with no historyof clubfoot.

Both treatment groups had strengthand motion deficits compared with the con-trol group, but the group treated with thePonseti method had better outcomes thanthe surgical group in many areas.

For example, individuals in the Ponsetigroup demonstrated significantly greaterankle plantar flexion range of motion (ROM),greater ankle plantar flexor and evertorstrength, and a lower incidence of os-teoarthritis in the ankle and foot. Addition-ally, the researchers found significantlyhigher pain levels in the surgical group thanin the Ponseti group, as well as significantlyreduced gait speed and stride length andmore time spent in double support.

Overall, the study supports efforts tocorrect clubfoot with the Ponseti method,which minimizes surgery to joints to pro-mote ROM and strength—essential ele-ments of adult functioning in the years aftertreatment. The findings were epublished in November 2013 Clinical Orthopedics andRelated Research.

Children in the Ponseti group began re-ceiving treatment an average of 12.4 daysafter birth. The Ponseti method, developedby Ignacio Ponseti, MD, consists of manip-ulation of the foot and casting. Casts arechanged weekly with gradually increasingcorrection and, at the final stage (after aboutfour weeks), surgeons do a heel cord teno-tomy to achieve a plantigrade position ofthe ankle and foot, according to Peter Smith,

MD, principal investigator of the study andan orthopedic surgeon at Shriners Hospitalfor Children in Chicago. Patients then under-went abduction bracing with a Denis-Browne bar and straight laced shoes, whichthey wore full time for two months, followedby nighttime use for four years.

Children in the surgical group hadbeen treated with conventional casting andhad an inadequate response or were ap-proaching age 18 months (the cut-off agefor corrective surgery), and subsequentlyunderwent surgery, a comprehensive club-foot release with a Cincinnati incision.

Despite the growing popularity andpositive outcomes associated with the Pon-seti method, there are some situations in

which surgery might still be used. Accordingto John Herzenberg, MD, director of Pedi-atric Orthopedics at Sinai Hospital and di-rector of the International Center for LimbLengthening, both in Baltimore, MD, parentsmust play a large role in treatment for thePonseti method to work effectively.

“Less parent participation and compli-ance is needed for surgery than the Ponsetiapproach,” Herzenberg said. “The Ponsetiapproach consists of three years of castingby the physician and then four years ofbracing, which has to be supervised daily bythe parents. Some parents are not able tomaintain this protocol, for a variety of rea-sons.”

Herzenberg cited social and economicbarriers as issues that can adversely affectcompliance.

The study’s limitations may have hadsubstantial effects on the data collected.

Most importantly, there exists a strong pos-sibility of selection bias, as all patients in thestudy who underwent Ponseti method ther-apy received that treatment at the Universityof Iowa Hospital and Clinics in Iowa City,where surgeons have used the Ponsetimethod for decades. All individuals in thesurgery group were treated at the ShrinersHospital for Children in Chicago, where sur-gery was the standard of care at the time forpatients in whom conventional castingfailed. The Ponseti method is now the stan-dard clubfoot treatment at Shriners.

Clubfoot patients treated in more re-cent years have likely benefited from ad-vances in treatment protocols, Smith said.

“We are always trying to speed correc-tion and prevent recurrence through bettercasting and bracing, and it is definitely afield that is improving,” he said. “We thinkthe outcomes are a bit better, particularly inachieving initial correction of the foot intoan abducted position to prevent recurrenceand meticulous detail to bracing. But thereis still an intrinsic nature of clubfoot that wedon’t understand that seems to result in di-minished strength and motion to a varyingdegree—even with the best current tech-niques.”

Samantha Rosenblum is a journalism studentat Northwestern University in Evanston, IL.Source:Smith PA, Kuo KN, Graf AN, et al. Long-term resultsof comprehensive clubfoot release versus the Ponsetimethod: Which is better? Clin Orthop Relat Res 2013Nov 19. [Epub ahead of print]

The study supports clubfoot

correction with the Ponseti

method, which minimizes

surgery to joints to promote

ROM and strength.

Photo courtesy of MD Orthopaedics.


Ankle dorsiflexion patterns varyin Charcot-Marie-Tooth diseaseData support case-by-case approachBy Larry Hand

Gait patterns can vary significantly amongyoung patients with Charcot-Marie-Toothdisease (CMT), and pathomechanics canvary even between limbs in one child, ac-cording to a recent study published in Gait& Posture.

This underscores the need for lowerextremity practitioners to evaluate eachchild’s gait individually rather than rely ona textbook definition of CMT, according tostudy author Sylvia Õunpuu, MSc, directorof research at the Center for Motion Analy-sis at Connecticut Children’s Medical Cen-ter in Farmington.

Õunpuu and colleagues retrospec-tively analyzed 33 children and adoles-cents (aged 12 ± 4 years) with CMT whounderwent motion analysis and clinical ex-amination while being evaluated for ortho-pedic surgery between 1990 and 2011.They compared data on patients with CMTwith data on an age-matched controlgroup of typically developing children.

Delayed peak dorsiflexion in terminalstance was seen in 59 of 66 limbs, and insome cases was the only gait abnormalityfound. This suggests delayed peak dorsi-flexion may be the first gait-related sign ofCMT, representing a major finding, accord-ing to Õunpuu.

Although the authors considered pa-tient data initially as a single group, the ev-idence led them to subsequently dividepatients into three subgroups based onpeak ankle dorsiflexion in terminal stance,which is affected by plantar flexor length,plantar flexor strength, and cavus foot pos-ture. Nineteen patients (30 limbs) had typical peak ankle dorsiflexion, eight pa-tients (13 limbs) had less than typical dor-siflexion, and 14 patients (23 limbs) hadexcessive dorsiflexion. The findings werepublished in the September 2013 issue ofGait & Posture.

“One of the primary messages fromthis paper is that the orthopedic textbooksgenerally describe CMT as a certain set ofconditions and, therefore, a certain set oftreatments,” Õunpuu said. “CMT presents

in many different ways and the degree ofseverity differs from patient to patient;therefore, treatment differs from patient topatient.”

In addition, gait pathomechanics maybe asymmetrical in patients with CMT, sheadded, with some patients having one limbin the typical peak ankle dorsiflexion sub-group and the other limb in a different sub-group.

“Understanding that, and understand-ing maximum ankle dorsiflexion duringgait and the extent of cavus deformity andplantar flexor strength and how these find-ings interact in each patient is really impor-tant for making an appropriate decisionaround treatment,” she said.

Ankle foot orthoses (AFOs) and otherinterventions can be used to addresscavus foot presentation, excessive ankledorsiflexion due to plantar flexor weak-ness, and plantar flexion contracture thatresults in limited dorsiflexion. However, cli-nicians need to be aware that overcorrec-tion can create a new set of gait-relatedissues, the authors noted, and specifiedthat surgical lengthening of the plantarflexors is not recommended.

“Two important goals an AFO shouldachieve are, first, to limit excessive dorsi-flexion and allow weight bearing on thedistal portion of the foot to provide morestability, and, second, to control cavovarusfoot presentation to prevent plantar flexioncontraction,” said Sean McKale, CO, LO,practice manager of Midwest Orthotic andTechnology Center in Chicago, and amember of the Charcot-Marie-Tooth Asso-

ciation (CMTA) advisory board. “This may be why we generally have

had more success with ground reactionstyle and carbon fiber AFOs, and workingwith manufacturers to customize a stiff-ness profile for a particular individual. Ad-ditionally, using casting techniques andextrinsic lateral forefoot posting to main-tain neutral coronal foot position has al-ways been important to improve balanceand distribute weight more evenly acrossthe forefoot,” he said.

Practitioners are often better able toaddress gait-related CMT issues whentreating patients as children than as adults,said David Misener, CPO, of Clinical Pros-thetics and Orthotics in Albany, NY, who isalso on the CMTA advisory board.

“Typically you’re able to push childrena little bit harder,” Misener said. “Theirbodies are little bit more elastic thanadults’ and you can be a little bit more ag-gressive. Typically there are fewer psy-chosocial issues for children, and they aremore willing to wear a device.”

Larry Hand is a writer in Massachusetts.Source:Õunpuu S, Garibay E, Solomito M, et al. A compre-hensive evaluation of the variation in ankle functionduring gait in children and youth with Charcot-Marie-Tooth disease. Gait Posture 2013;38(4):900-906.

Delayed peak dorsiflexion,

which was seen in almost all

study participants, may be

the first gait-related sign of

Charcot-Marie-Tooth.

Photo courtesy of the CMTA.


Ankle weights improve walkingin children with Down syndrome Load may help engage plantar flexorsBy Larry Hand

Adding an ankle load during treadmillwalking significantly improves gait kineticsin children with Down syndrome (DS), pos-sibly due to greater contributions from theankle plantar flexors, according to a studyfrom Georgia State University in Atlanta.

Jianhua Wu, PhD, assistant professorof kinesiology and health at Georgia Stateand coauthor Toyin Ajisafe, a graduate stu-dent, investigated effects of walking speedand external ankle load on the kinetic pat-terns of treadmill walking in preadoles-cents with DS and a comparable group oftypically developing children.

Ten children with DS and 10 typicallydeveloping children (eight boys in eachgroup; average age 9 years) participatedin treadmill tests performed at two speeds(75% and 100% of preferred walkingspeed) and two ankle-load conditions (noankle load or with ankle loads equal to 2%of the participant’s body weight). Theadded ankle load, applied using 1.25-lbweights from a sporting goods store, wasintended to create a 39% increase in themoment of inertia for each leg at the hipjoint.

The researchers instructed children towalk on the treadmill without placing theirhands on the handrails, and provided ver-bal encouragement to the children withDS as needed during the tests. The re-searchers used a seven-camera motioncapture system to collect kinetic and kine-matic data, but, for this study, analyzedonly the kinetic data.

Compared with the typically develop-ing children, the children with DS had ashorter duration of propulsion during pushoff, a smaller second ground reaction force(GRF) peak and vertical propulsive impulse,a higher loading rate, and a lower unload-ing rate. The magnitude of the second GRFpeak in the children with DS was smallerthan body weight, a characteristic that is as-sociated with typically developing childrenat younger ages, who tend to use the hipextensor muscles during push off ratherthan the ankle plantar flexor muscles.

Walking at a faster speed helped thechildren with DS improve the duration ofpropulsion, vertical propulsive impulse,and unloading rate, but the second GRFpeak actually decreased further. However,the added external ankle load helped in-crease the second GRF peak as well asthe vertical propulsive impulse, suggestingthat the weights helped the children en-gage the ankle plantar flexors even atfaster speeds. The findings were publishedin January by Gait & Posture.

“Inclusion of external ankle load maybe a promising approach to strengtheningleg muscles and eliciting a more powerfulpush off in persons with DS,” the authorswrote.

“Children with DS had little experi-ence walking on a treadmill before thisstudy,” Wu said. “However, the majority ofthem successfully walked on a treadmill attwo speeds, slow and fast. It was surprisingto their parents that their child could walkon a treadmill without holding thehandrails. I think, with careful administra-tion and appropriate monitoring, we canuse certain paradigms such as treadmillwalking to expand the motor repertoire ofchildren with DS.”

This could help children with DS onmore than a physical level, Wu said.

“A higher level of motor capability willcertainly get children with DS more en-gaged in physical activity and sports. Thismay benefit children with DS not only atthe physical health level, but also at thepsychological and mental levels,” he said.

Kathryn Martin, PT, DHS, professorand Doctor of Physical Therapy programdirector at the Krannert School of PhysicalTherapy at the University of Indianapolis inIndiana, said the study highlights one pos-sible way to improve strength and increasephysical activity in children with DS.

“In my opinion, we cannot correct hy-potonia or ligamentous laxity, but we canimprove strength. Improving strengthshould help minimize compensations.Adding ankle load is one way to improvestrength,” Martin said.

However, she noted that the effectiveuse of treadmill technology in this patientpopulation may be challenging for someclinicians.

“Children with DS always have somedegree of intellectual disability,” she said.“Motivating them to walk on a treadmillmay be more challenging than for typicallydeveloping kids, as the task may just notbe meaningful to a child with DS. Physicaltherapists have to find ways to make thesekinds of activities fun in order to encour-age a child with DS to participate.”

Larry Hand is a writer in Massachusetts.Source:Wu J, Ajisafe T. Kinetic patterns of treadmill walkingin preadolescents with and without Down syndrome.Gait Posture 2014;39(1):241-246.

The added external ankle

load helped increase

the second GRF peak

as well as the vertical

propulsive impulse.

Photo courtesy of SureStep.

Adolescents and children suffer morecomplex meniscus injuries that are oftenless repairable than previously reported,according to a study published in the De-cember 2013 issue of the American Jour-nal of Sports Medicine (AJSM).

The study included 293 patients agedbetween 10 and 19 years who underwentarthroscopic meniscus surgery. Nearly allwere active in sports, but factors contribut-ing to greater complexity of the meniscaltears—which can adversely affect re-pairability—were obesity and male gender.

“Both obesity and boyhood carry anincreased capacity for tear potential,” saidstudy author Eric Edmonds, MD, who spe-cializes in orthopedic surgery at Rady Chil-dren’s Specialists of San Diego inCalifornia.

Meniscal repair has demonstratedbetter long-term outcomes over partialmeniscectomy in adults. A 2010 studyshowed no evidence of osteoarthritic ad-vancement in 80.8% of patients a mean of8.8 years after repair compared with 40%after meniscectomy.

“We recommend repair, if we can,”said Kelly Vanderhave, MD, who special-izes in pediatric orthopedic surgery at Car-olinas HealthCare System in Charlotte, NC.“Previous studies have shown that, if youtake it out, you advance arthritis prettyquickly. If it’s at all repairable, I repair it.”

In the AJSM study, adolescent boyshad a lower repair rate (41%) than adoles-cent girls (56%). Nearly one-third (32%) ofthe boys had complex tears, comparedwith just 20% of the girls studied, whichalso translated to lower repair rates amongboys. Patients with complex tears also hada significantly higher body mass indexthan those with noncomplex tears (27.4 vs25.1), though the study did not examinethe relationship between body mass indexand repair rates.

Meniscal injuries often present withother acute injuries such as anterior cruci-ate ligament (ACL) tears, chondral injuries,and tibial fractures. Although the correla-

tion hasn’t been studied specifically, it’slikely that, just as pediatric anterior cruci-ate ligament (ACL) injury rates are on therise, so too are pediatric meniscal injuries,Vanderhave said.

“They tend to go together,” Vander-have said. “I think kids’ activity levels haveincreased overall. The number of sports in-juries I see now is ten times what I saw tenyears ago.”

Not all of the meniscal tears in theAJSM study were associated with ACL orother ligament injuries. The presence ofligament injury didn’t affect meniscal re-pair rates, said study coauthor Andrew T.Pennock, MD, who also specializes in or-thopedic surgery at Rady Children’s Spe-cialists of San Diego.

However, the authors did find thatearlier treatment may increase the likeli-

hood of repair in younger patients. Thosetreated within three months of injury weremost likely to have repair, at a rate of 56%,compared with only 42% who weretreated more than six months after injury.The repair rate for adolescents was evenmore dramatic, dropping from 58% atthree months to 37% at six months.

Pennock noted a variety of reasonswhy surgeries are sometimes deferred, butdelayed presentation led the list.

“Some are delayed presentation—thefootball player who didn’t want to come inmidseason—some are patients who under-went a nonoperative course that failed,and others are delays in the workup, in-cluding a referral to the orthopedic sur-geon, an MRI, and surgical booking or

authorization,” he said.Such delays increase the likelihood

that a young, active patient will do furtherdamage to the initial injury.

“Kids are very determined and re-silient,” Edmonds said. “They often pushthrough injuries because they don’t havethe life experience to understand that youcannot just bounce back from all boo-boos. In that process, they continue to ex-tend the injury past its originalconfiguration. This can change from fix-able to nonfixable.”

The surgical approach was typicallydetermined by the type of the meniscaltear, in conjunction with the tear location,patient age, and chronicity of the tear. Inthe vast majority, surgeons did a partialmeniscectomy if a repair was not possible.

“The reparability of the meniscus tearwas determined by the surgeon at thetime of surgery,” said Pennock. “In general,less complex tears in the red-white or red-red zone [at the outer edge of the menis-cus] have the best healing potential andare the most likely to be repaired.”

P.K. Daniel is a freelance writer and editorbased in San Diego, CA.Sources:Shieh A, Bastrom T, Roocroft J, et al. Meniscus tearpatterns in relation to skeletal immaturity: childrenversus adolescents. Am J Sports Med 2013;41(12):2779-2783.Stein T, Mehling AP, Welsch F, et al. Long-term out-come after arthroscopic meniscal repair versusarthroscopic partial meniscectomy for traumaticmeniscal tears. Am J Sports Med 2010;38(8):1542-1548.

Young athletes, particularly

adolescents, treated within

three months of surgery

were most likely to be

eligible for meniscal repair.

In youth athletes, repair aftermeniscal injury poses challengeObesity, gender affect tear complexityBy P.K. Daniel


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New flatfoot data rekindle debate over role of obesity

Australian researchers found no correla-

tion between body mass index and preva-

lence of pediatric flatfoot, but used a

different methodology than previous stud-

ies that reached an opposite conclusion.

The conflicting results have revitalized the

ongoing debate on this topic.

By Cary Groner

Over the years, researchers have claimed to discover significantcorrelations between childhood obesity and pediatric flatfoot. Onewell-known study by Pfeiffer et al, for example, examined 835 chil-dren aged 3 to 6 years and concluded that flatfoot prevalence wasinfluenced by three factors: age (flatfoot was more common inyounger children), gender (boys had a higher prevalence), andweight (42% of normal-weight kids had flat feet vs 51% and 62%of those who were overweight and obese, respectively).1 Otherstudies have reached similar conclusions.

Recent research has called such findings into question, how-ever, and resurrected the controversy about which children shouldbe treated. In a paper presented at the 2013 Australasian PodiatryCouncil Conference in Sydney last June2 and currently in press withthe Journal of Foot and Ankle Research, Angela Evans, PhD, exam-ined body mass index (BMI) and foot posture index (FPI) scores for698 children and found no correlation between BMI and flatfootprevalence. The work expanded on an earlier study reporting similarfindings in 140 children.3

“These studies conflict with previous studies that found a cor-relation, even though intuitively that correlation makes sense,” ac-knowledged Evans, who has a private practice in Adelaide, Australia,and a research position at La Trobe University in Melbourne. “Partof the problem may be that most of those studies used a footprint-based method of assessing foot posture.”

Footprint measures raise an obvious question in the case ofobese children: are the feet flatter or merely fatter? That is, whenmore adipose tissue is compressed under the child’s weight, doesthis merely create the impression of a flatter foot? The question hasprovoked significant debate—not only regarding the value of differ-ent assessment methods, but also in terms of its clinical implica-tions.


Footprint measures raise an obviousquestion in the case of obese children:are the feet flatter or merely fatter?

Istockphoto.com #24127457

The evidenceThe evidence supporting the link between weight and flatfoot isn’tcopious, but much of it seems plausible enough. For example, in apaper that appeared in 2006 in the journal Obesity, Australian re-searchers compared the feet of 19 overweight or obese preschoolchildren with those of 19 controls matched for age, height, and sex.They concluded that there was no difference between groups in thethickness of the midfoot plantar fat pad, which was measured withultrasound. But the heavier kids had a significantly lower plantararch height, assessed via plantar footprints.4 Although footprintsthemselves may not offer a particularly robust evaluation tool, whenthe fat pad variable is accounted for, they seem more persuasive—or might, perhaps, in a larger sample size.

Another small study, this one from the US, reported similar find-ings in 2012, noting that obese children had less ankle dorsiflexion,resulting in longer foot contact time during stance, as well as signif-icantly more flexible feet and greater arch drop.5

Some studies have been done in older children, which cancomplicate the comparison of results because their feet have hadmore time to develop. Nevertheless, a 2007 study of 200 Scottishchildren aged 9 to 12 years reported that foot length and width weregreater, while navicular height was lower, in the heavier children.6

And a 2009 study from Spain evaluated foot arch types in 58 obeseyouths aged 9 to 16.5 years using both footprints and lateral weight-bearing radiographs, compared to the same number of normal-weight controls. Both measures found a lowering of the mediallongitudinal arch in the obese children.7

A particularly interesting study was conducted in Spain andpublished in the European Journal of Pediatrics last year.8 Re-searchers used a 3D digital scanner to evaluate the foot morphol-ogy of 1032 schoolchildren aged 6 to 12 years, and reported thatthe arches of the obese children didn’t develop as fast as those ofthe normal-weight kids. A closer look at the reported data revealsodd contradictions, however. For example, the arch height of nor-mal-weight children increased at an annual rate of 4.8%, whereasfor obese children the rate was 3.7%. That fits the pattern; however,the rate for overweight kids, who were assessed separately fromthe obese ones, had a rate of 6.1%—higher than that of the normal-weight children.

Measurements Clinicians and researchers can be forgiven for scratching theirheads when faced with such data. Many now tend to draw conclu-sions tentatively, if at all. Angela Evans’s papers provide an exampleof how quickly things can shift, in fact.

In terms of her own research, she attributes the change of per-spective to use of the FPI.

“The difference in our study that really stood out was the waywe assessed foot posture,” she said. “We know that the FPI is fairlyreliable; it has tested validity and is widely used clinically. So whenwe found these differences [vs previous research], we wonderedwhat was going on. Our first study was small, but in the second onewe got the same results in about seven hundred kids. There wasnot an association between increasing body mass and the rate offlat feet when measured by the FPI.”

Evans doubts the validity of footprint-based evaluations, and

Continued from page 9


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notes that even radiographic findings are problematic becausethere aren’t a lot of normative data to compare them with (not tomention the ethical issues that would be associated with subjectingschoolchildren to mass x-ray screening to gather those data).

But how about the FPI itself? Is it a valid assessment tool inobese children?

Anthony Redmond, MD, a researcher at the University of Leedsin the UK, who was largely responsible for developing and validatingthe FPI, told LER via email that it was originally designed as a meas-ure for pediatric foot posture and was carefully validated in thatrole.9

“Re: childhood obesity, that is a different story altogether,” Red-mond wrote. “[There are] problems with the use of footprint meas-ures…and to some degree the same applies to the FPI and to anyexternal measures of foot posture. Where the research question re-lates specifically to obesity, in my view the only valid measures ofposture/alignment will be those that use internal imaging to visualisebone alignment directly.” Examples of such imaging modalitieswould include x-ray, magnetic resonance imaging, computed to-mography, or radiostereometric analysis.

“I don’t think technically I absolutely agree,” Evans responded,when read this email. “The point is that the different measures haveshown conflicting results. The FPI is widely used by clinicians, and Idon’t think they have any sense of it being restricted regarding theincidence of childhood obesity.”

Clinical implicationsBetter clinical practice is, after all, the main point of sorting out suchmatters.

“Childhood obesity is terribly concerning from a wider healthperspective,” Evans continued. “How much we need to worry aboutits relationship to foot posture is still undetermined, however, andI’m concerned that overdiagnosis may lead to unnecessary inter-vention.”

In the experience of Alan Ng, DPM, who practices with Ad-vanced Orthopedics and Sports Medicine Specialists in Denver, CO,pediatric flatfoot has more to do with genetics than overweight.

“I lean toward agreeing with Evans on this issue, because in thekids I see, biomechanics are primarily based on genetics,” he said.“Later in life, if they maintain an elevated BMI, they may developflatfoot secondary to overload and posterior tibial tendon dysfunc-tion. But at that early stage, I don’t think childhood obesity reallyleads to flatfoot.”

Regardless of the patient’s weight, Ng decides whether to treatbased on symptoms—and not just pain.

“If they come in complaining of tripping, or that they get too fa-tigued doing athletics at school, we assess them,” he said.

High on his list is checking for a secondary accessory ossicleor an os tibiale externum on the medial aspect of the navicular.

“They can have symptoms when they have a connection betweenthat bone and the navicular, and the area gets irritated,” he explained.

Edwin Harris, DPM, associate professor of orthopedics and re-habilitation at Loyola University Medical Center in Maywood, IL, con-curred with Ng about obesity and flatfoot.

“I tend to agree with the conclusions that increased BMI prob-ably doesn’t correlate with pronated feet,” he said. “My patients in-clude just as many skinny kids as obese kids, though it is harder tomanage obese kids with orthotic devices.”


Continued on page 12

Harris pointed out that most of the literature relating BMI andflatfoot focus on arch height—which, as noted, is difficult to quantifyclinically.

“There are no proven ways of measuring it unless you do it ra-diographically,” he said. “People say they’re going to measure thedistance between the navicular and the floor, but I’m not sure howprecise that measurement is, or whether I could duplicate it, due toall the variables.”

Harris also noted that researchers and clinicians are workingwithout a particularly good definition of what constitutes flatfoot.

“It’s really a three-plane deformity, but most of the articles lookat it only in the sagittal plane,” he explained. “That’s not really a goodindicator of what’s going on.”

He, too, limits his treatment to those with symptoms, includingpain in the arch.

“Pronated feet have a whole slew of morbidities other than obe-sity,” he said. “Some children are hypotonic or have other risk fac-tors for muscle imbalance. But when they complain of pain, I listento them and look at them carefully.”

Russell Volpe, DPM, who practices in Manhattan and is a pro-fessor of orthopedics and pediatrics at the New York College of Po-diatric Medicine, said that the relationship between obesity andpediatric flatfoot is more complicated than simple cause and effect.

“Inactivity contributes to obesity, so we want to keep kids as activeas possible,” he said. “From the podiatric perspective, if they have flat-ter, more pronated feet, and if that contributes to inactivity, then wehave a vicious cycle that might lead to significant disability and wors-ening of obesity over time, which would be well worth avoiding.”

Asked whether only symptomatic children would likely curtaintheir activities, however, Volpe dissented.

“I’m not ready to concede that only symptomatic kids becomeless active,” he said. “There is such a thing as a presymptomaticchild, and those of us treating children with flat feet need to bemindful of that. When we identify those, we need to do somethingto help them function better. Most of the time, when an older childor an adult comes to us with a mechanical foot problem, it’s beenyears in the making.”

Volpe considers BMI just one among a host of factors that helpdetermine a clinical pathway.

“No kid is going to be in or out of the treatment group just be-cause they’re heavy,” he said. “Obesity is interesting from a re-search, screening, and risk standpoint, but I’m not going to be theone saying, ‘Give all the fat kids orthotics.’ It’s just one more thingon my list of reasons when I decide to intervene or not.”

Volpe noted, moreover, that much of the discussion about obe-sity and flatfoot has turned on measurement.

“Angela points out that the footprint method is flawed; shehangs her hat on the FPI having normative value, and I’ll give herthat,” he said. “But Tony Redmond now seems to be saying that theFPI is not the be-all and end-all, either. That Angela’s studies haven’tfound a correlation may also be a measurement flaw, though in fair-ness to her, she acknowledges that in her conclusion. I’d be hard-pressed as a scientist and an academic to dismiss her work; I thinkit’s worthy of our attention. But I think we need to look further;there’s probably a bigger and better study to be done to see if wecan settle this definitively.”



More studiesAs it happens, recent research has shed light on which patients with

flexible flatfoot are most likely to become symptomatic. In a study

conducted at Rady Children’s Hospital in San Diego, researchers

looked retrospectively at 135 patients, 45 of whom were asympto-

matic. As assessed by standing anteroposterio and lateral radi-

ographs, the authors concluded that lateral displacement of the

navicular seemed to be related to symptom onset.10

“This may be an area we look at more carefully in the future,

and it may start to simplify this whole debate,” said Evans.

In the meantime, however, she and her colleagues are about

to embark on further research at La Trobe. The study will compare

footprint measures, FPI, and the results of external 3D digitized foot

scanning to evaluate their relative strengths and weaknesses.

“We need to clarify this discordance,” she said. “We’re hoping

that this independent 3D imaging will teach us more about both of

those measures. It’s quite exciting.”

Cary Groner is a freelance writer in the San Francisco Bay Area.


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Strength training improvesfunction in children with CP

Research suggests strength training can

improve gait and function in children with

cerebral palsy. But to be successful,

experts say, the training needs to be part

of a multifaceted rehabilitation program

that accounts for more than the physical

limitations imposed by the disease.

By Shalmali Pal

The merits and drawbacks of strength training in children with spas-tic cerebral palsy (CP) have been the subject of debate, but TylerSexton, MD, has no doubts about its benefits.

Diagnosed with spastic diplegia, the most common form of CP,Sexton underwent 16 surgeries during his formative years, includingselective dorsal rhizotomy at age 4 years, which helped him tradein a wheelchair for a walker; Achilles tendon lengthening; hamstringand adductor lengthening; and repairs to the lateral collateral liga-ment and meniscus in his left knee.

“I always kept up with my strength training and aggressive phys-ical therapy [PT] before and after my various surgeries,” Sexton ex-plained. “I saw great improvement with strength training, specificallycycling. [It] was the best way to gain function and mobility. I rode athree-wheel bike and now I’m on a stationary bike. I still do thisevery day, and I’m 28.”

Gaining strength, mobility, and function gave Sexton the abilityto achieve his goals: weaning himself from his ankle foot orthoses(AFOs) by age 13 years, learning to drive a car, earning the title ofscuba divemaster, and becoming a pediatrician who specializes inhyperbaric medicine.

Sexton, president and chief executive officer of Caribbean Hy-perbaric Medicine in Zephyrhills, FL, and a clinical professor of hy-perbaric medicine at the University of Southern Alabama in Mobile,now works with children with disabilities, including CP, and is an ad-vocate for strength training.

“I believe it does help with mobility and spasticity,” he said. “Iknow the literature hasn’t always found that to be true, but...I believein the ability of strength training in CP. In myself and my patients,I’ve seen an increase in range of motion, a decrease in pain in thehips and knees, and an increase in endurance.”

One piece of the puzzleBut Sexton, along with the other experts that LER spoke with,doesn’t believe strength training (with diplegia or hemiplegia) is theultimate panacea for gait and function issues in kids with CP. For


Many children with cerebral palsy havethe same hopes and dreams as kidswithout CP, which can be an importantconsideration during training.

Photo courtesy of Kennedy Krieger Institute.

strength training to be successful in this patient population, expertssay, it needs to be part of a multifaceted rehabilitation program thattakes into consideration more than the physical limitations imposedby the disease state.

“Children with CP are weak almost everywhere, so why not try toget them as strong as their able-bodied peers? Then get them to applythat strength and flexibility to whatever they want to do in their lives,”commented Jack Engsberg, PhD, director of the Human PerformanceLab at Washington University in St. Louis. “I think the same principlesfor strength training that apply to people without disabilities apply tothose with disabilities. But you have to consider what the disabilitiesare, and design a program based upon that.”

The goal of strength training in children with CP is not to produce

the same results as body builders, stressed Christopher Joseph, MSPT,director of PT at the Kennedy Krieger Institute in Baltimore.

“We are looking to strengthen them within their abilities,” Josephsaid.

Orthopedic surgeon Lance Silverman, MD, of Silverman Foot &Ankle in Edina, MN, said he is a believer in postsurgical PT in general,but cautioned, “Strength training by itself is a mistake because it willonly strengthen the dysfunction instead of properly correcting theproblem.”

A sound strength-training regimen will correct dysfunctionalmovement and then work to improve functional movement, Silvermanexplained.

“It is the same process that would be used with a healthy popu-lation; it’s just more challenging to do correctly with CP patients,” hesaid.

Patient selectionStudy results for strength training in children CP have been mixed.1-6

Authors of a 2012 meta-analysis7 concluded that, while some indi-viduals benefit from progressive strength training, it’s unlikely to bethe optimal therapy for all patients with CP.

Engsberg, who is also a professor of occupational therapy, neu-rosurgery, and orthopedics, suggested the studies that did not showa good result from strength training did not aim for enough of astrength increase.

“These kids are already at thirty percent in terms of strengthversus able-bodied kids, so a ten percent increase isn’t going to re-ally benefit them,” he said. “You want to show a dramatic change inthe strength component—sixty percent or more—so you have to tailor the training accordingly.”



Figure 1. A teenage patient with CP performs lower body strength training. (Imagecourtesy of the Cerebral Palsy Alliance.)

But the experts agreed with the meta-analysis authors that pa-tient selection is key. For example, kids with a Gross Motor FunctionClassification System (GMCFS) score of IV or V—in which independ-ent mobility is either very limited or nonexistent—may not be goodcandidates for strength training.

“If I have a patient who I do not expect to walk after surgery,then I’m less likely to say that strength training is worthwhile,” Sil-verman said. “If I have a patient who I expect to have a productivegait after surgery, but is having a difficult time with balance and co-ordination, then I think strength training has value.”

The International Classification of Functioning, Health and Dis-ability (ICF) has become a common tool for assessing disability, andultimately, a child’s capacity for strengthening.

“The ICF considers the body structures and function aspect ofa health condition/disability, the impact on activity, and the impacton participation,” explained Prue Golland, a consultant in physio-therapy at the Cerebral Palsy Alliance in Allambie Heights in NewSouth Wales, Australia, in an email. “In simple terms, muscle weak-ness is considered to occur at the body structures level whilst walk-ing is at the activity level. The literature8 suggests that interventionsare generally effective at one level of the ICF only.”

Age and CP-related cognitive deficits are also considerationswith regard to the child’s ability to follow directions.

Joseph explained that, at a very young age, most children withCP still learning effective motor patterns. If they struggle early on,that can lead to muscle weakness.

“When we start strengthening at an early age, we do it in a func-tional context. We’ll load them with a weight or put them in a con-text where they have to carry most of their body weight,” he said.“For instance, walking up steps. We may not start steps with a

healthy eight-month-old because they can’t walk, but we may startsteps in an eight-month-old CP kid because we want to strengthenthe thighs and calves, and have the child learn the correct motor pattern.”

At the Cerebral Palsy Alliance, therapists reserve progressiveresistance strength training for children older than 8 years; func-tional strength programs utilizing goal-directed therapy are used inyounger children, Golland said.

Finally, Sexton said he does not advise strength training in chil-dren whose CP is complicated by severe cardiac abnormalities orbronchopulmonary dysplasia or in those with self-harming behavior.

Factors to considerStrengthening programs are generally based on the guidelines fromthe American Academy of Pediatrics and the National Strength andConditioning Association, Golland pointed out. But training ap-proaches and protocols still need to be determined on a case-by-case basis.

At Kennedy Krieger, therapists use both the split treadmill andaquatherapy for strength training.

While motor activity is the primary aim of a split treadmill work-out, it can offer some benefits for endurance and strengthening,Joseph said.

“Let’s say the child is hemiparetic on the right side. I can sether up so that the treadmill is going at the normal speed—about 1.5to 2.2 miles per hour for an average child—on the left side. On theright, I can speed the treadmill up so that she has to concentratemore on that right leg,” he said.

A CP patient who has severe contraction and is unable to pas-


Continued on page 18

sively move her limbs may not be a candidate for cycling therapy,Sexton said, and would be better served by aquatic therapy or evenresistance band training.

Sexton said he believes an effective strength-training regimenwill incorporate antispastic medication, such as onabotulinumtoxinA(Botox) and baclofen. However, he emphasized that dosing of anti-spastics must be titrated properly to help control spasticity withoutlimiting the patient’s ability to work their muscle groups and followthe training protocol.

Joseph concurred.“Some kids use their spasticity and their muscle tone, even if

it’s low, to function,” he said. “We don’t want to completely takeaway their spasticity and that muscle tone.”

AFOs can be a help or a hindrance, depending on the patient.Engsberg pointed out that, if a patient is wearing a rigid AFO but istrying to gain more ankle strength, then the AFO isn’t going to helpwith the latter if it prevents ankle motion.

“However, if a child is unable to walk without the AFO, then per-haps the goal with ankle strengthening might be to transition awayfrom the rigid AFO to a flexible one,” he said.

And, even if an AFO does restrict ankle movement, the addedstability may facilitate strengthening the muscles around the kneeor hip, Golland said.

Joseph said that his group is getting away from orthoses in gen-eral and setting patients up with functional electrical stimulation(FES) units, in some cases while the patient is still wearing a post-operative cast.

“If we have concerns about the muscle getting weaker, we’llcut a window in the cast and apply the FES, working within the pa-rameters set by the physician,” Joseph said.

Time One limitation of the published studies in this area is that the dura-tion of strength training—generally around eight weeks—may nothave been long enough for researchers to see visible functional im-provements.

This is particularly true for patients who have recently under-gone postoperative casting, Silverman said.

“It’s going to be several weeks after surgery before a CP patientis going to be able to recoordinate the body. You have to keep thattimeline in mind before you determine when to begin strength train-ing and how long it should be done,” he said.

Engsberg explained that a strength training protocol starts withlearning proper technique, which in itself can take a couple of months.



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Figure 2. Tyler Sexton, MD, chats with a patient. (Photo by Bill Starling.)

“Then you start getting into the building of muscle mass,” hesaid. “So strength training programs that only go for four or sixweeks are not really getting into the two important components thatmake strength training worthwhile.”

Rather than keeping a strict timeline for seeing results, the ther-apists at Kennedy Krieger follow the child’s progress in terms offunctional gains, bearing in mind that, the younger the child, themore time progress will require.

“If we have a CP child who walks at age two, we’re going towork with them from twelve to sixteen months on strengthening ina functional context,” Joseph said. “As they get older, then we maybe able to focus on a more traditional strengthening protocol be-cause they can follow directions better.”

Sexton also emphasizes to his patients and their caregivers thatthey may not see the benefits of strength training in the short term.

“In the long run, they will have better mobility; they will havebetter range of motion. All of that is more likely to get them closerto their goals,” he said.

Goals and motivationSexton pointed out that many children with CP have the same hopesand dreams as kids without CP, which can be an important consid-eration in training.

“I wanted to be [basketball player] Shaquille O’Neal when I wasyounger,” he shared. “I remember the therapists would say to me,‘Come on, Shaq, let’s do it,’ when I tried to get out of the wheelchairand walk. Was that the only thing that got me out of the wheelchair?No, but finding out what motivates a kid with CP and incorporatingthat into the strength training protocol is very important.”

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“you have to follow their lead and engage them as they are moving.Find out what seems to interest them, whether it’s walking the stepsor being in the water,” Joseph said.

For some CP patients—especially those with GMFCS classifica-tion I or II—the goal may not be to improve function, but simply tomaintain it, Golland said.

“Does function mean walking, getting up from the floor, orclimbing stairs? Or does it refer to someone’s ability to repositionthemselves in their wheelchair, or lean forward to assist a carer toreposition their clothing?”

Even small gains in strength may be empowering to a patientwith CP.

“Let’s say a CP child is going through a calisthenics-basedstrength training program, but they’re only seeing a ten percentgain,” Sexton said. “From a clinical perspective, that may not bemeaningful. But maybe that small gain allows that kid to feel like hecan go out for a walk with his dad or do some other activity.”

Joseph noted that patient-centered quality of life is becomingessential for measuring the success of a training program.

“That kind of information about the child and his real-life situa-tion can be much more useful [than more clinical measures] whenI look at what is, and is not, working for the child,” he said.

Shalmali Pal is a freelance writer based in Tucson, AZ.


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New flatfoot data rekindle debate over role of obesity ...€¦ · In addition, gait pathomechanics may be asymmetrical in patients with CMT, she added, with some patients having