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The Childhood Obesity Epidemic and Hypermobile Flatfoot
The Childhood Obesity Epidemic and Hypermobile Flatfoot Paul R. Scherer, DPM Clinical Professor College of Podiatry Medicine Western University of Health Sciences The Western Podiatric Medical Congress 2010 Short Code: 313131 Item Code: VTB4793 Financial Disclosure: ProLab Orthotics Stride Rite® Hypothesis Hypermobile pediatric flatfoot is a comorbidity of childhood obesity. Lecture Objective To reach a clinically significant conclusion through a review of recent literature and provide practice guidelines. Presentation and references at www.prolaborthotics.com Why Are We Here? How prevalent is childhood obesity? What is the evidence that childhood obesity has an effect on the lower extremity? Does childhood obesity cause flatfoot? What does the literature tell us about treating hypermobile flatfoot? What role should orthoses and shoes play in treating hypermobile flatfoot? Prevalence of Childhood Obesity 30% of U.S. children (aged 6-11 years) are overweight (BMI>85th percentile) 15.3% are obese (BMI > 95th percentile) BMI = weight (kg) height 2 (m) Krebs NF, Pediatrics 2003 Troiano R, Pediatrics 1998 Prevalence of Childhood Obesity 16.4% of children are obese in the U.S. • • • 14% White 20% Black 25% Hispanic Pomerantz WJ, Pediatrics 2010 Prevalence of Childhood Obesity in the US Global Prevalence of Childhood Obesity Lecture Guide How prevalent is childhood obesity? What is the evidence that childhood obesity has an effect on the lower extremity? Does childhood obesity cause flatfoot? What does the literature tell us about treating hypermobile flatfoot? What role should orthoses and shoes play in treating hypermobile flatfoot? Pediatric Obesity Comorbidity Obesity in childhood is the leading cause of : • • • • • Pediatric hypertension Type 2 diabetes Coronary heart disease Increased lower extremity injury Hypermobile flatfoot www.kidsource.com Pediatric Obesity Comorbidity Lower Extremity Injury Obese children have a 1.7x greater risk of LE injury including • • • • dislocations fractures lacerations sprains n=24,588 Pomerantz W.J. Pediatrics 2010 Pediatric Obesity Comorbidity Lower Extremity Injury Six months after Salter-Harris I injury, overweight children were more likely to sustain persistent symptoms than non-overweight (n=171) Timm NL, Arch Pediatr Adolesc Med, 2005 Lecture Guide How prevalent is childhood obesity? What is the evidence that childhood obesity has an effect on the lower extremity? Does childhood obesity cause flatfoot? What does the literature tell us about treating hypermobile flatfoot? What role should orthoses and shoes play in treating hypermobile flatfoot? Flatfoot and Obesity Garcia-Rodriguez 1999 (n= 1000) • overweight children have an increased prevalence of flatfoot Bordin 2001 (n=243) • flatfoot affects16% of non-obese children and 24.3% of obese children Dowling 2001 (13 obese,13 control) • obese children have higher forefoot peak pressures than non-obese Pfeiffer 2006 (n= 835) • pediatric flatfoot is influenced by age, gender, and especially weight Mickle 2006 (17 obese,17 control) • obese children have higher pressure-time integrals than non-obese Mickle 2006 (19 obese,19 control) • lower arch height in obese children is caused by structural changes Mauch 2008 (n= 2887) • flatfeet 2x more likely in overweight children than normal weight children Chen 2009 (n= 1024) • flatfoot in Taiwanese children: normal wt-27%, overweight-31%, obese-56% Lecture Guide How prevalent is childhood obesity? What is the evidence that childhood obesity has an effect on the lower extremity? Does childhood obesity cause flatfoot? What does the literature tell us about treating hypermobile flatfoot? What role should orthoses and shoes play in treating hypermobile flatfoot? Flexible Flatfoot Classifications Rigid Congenital • • Vertical Talus Calcaneal Valgus Developmental • • Metatarsus Adductus Skewfoot Cerebral Palsy Congenital Hypotonia Muscular Dystrophy • • Down Syndrome Marfan Syndrome Connective tissue disorders • • Neurologic/Muscular • • • Genetic Collagen/Elastin Ehlers-Danlos Idiopathic Hypermobile Flatfoot • • Symptomatic Asymptomatic (progressive) Flexible Flatfoot Clinical Findings Low longitudinal arch height Everted calcaneus Abduction of forefoot in stance Gait changes • • • Decreased stride length Decreased cadence Decreased velocity Equinus involvement How Should We Treat Hypermobile Pediatric Flatfoot? Are orthoses an effective treatment? UCBL Mereday 1972 n= 10 children Method • X-ray evaluation, UCBL for 2 years Results • • • Pain relief Gait improvement No lasting structural changes Mereday C, et al: Evaluation of the University of California Biomechanics Laboratory shoe insert in “flexible” pes planus: Clin Orthop Relat Res, 1972 UCBL Bleck 1977 n= 71 children Method • • • X-ray evaluation UCBL >1 year Results • • 79% improvement in clinical appearance and x-ray findings 1° improvement (lateral tarsometatarsal angle) every 2 months of use Bleck EE, et al: Conservative management of pes valgus with plantar flexed talus flexible: Clin Orthop Relat Res, 1977 Custom Foot Orthotic Bordelon 1980 n= 50 (3-9 y/o children) Results • 5° improvement of lateral tarsometatarsal angle annually • No loss of motion in ankle or STJ Method • Custom molded orthotic (1/8” poly) • X-ray evaluation by lateral tarsometatarsal angle Bordelon RL: Correction of hypermobile flatfoot in children by molded insert. Foot Ankle, 1980 Maintenance of Arch Bordelon 1983 n= 6 (5 y/o children) Method • Followed children from first study after orthotics discontinued Results • 5 out of 6 children maintained correction after discontinuation of corrective devices for 25 months Bordelon: Hypermobile flatfoot in children; comprehensive, evaluation and treatment. Clin Ortho Rel Research, 1983 Down Syndrome Gait Patterns Selby-Silverstein 2001 n=26 (3-6 y/o children) • 16 Down patients, 10 control patients Method • Motion analysis gait evaluation • Custom molded orthotics Results • Heel eversion decreased • Transverse plane angle reduced in gait • Improvement of ankle movement and stride length Selby-Silverstein, et al: The effect of foot orthoses on standing foot posture and gait of young children with Down syndrome. Neurorehab, 2001 Clinical Questions Could it be that the arch develops only in a stabilized midtarsal joint? Could stabilizing the midtarsal joint in flatfoot assist in more normal development of the arch? Can early intervention alter midlife outcomes? Lecture Guide How prevalent is childhood obesity? What is the evidence that childhood obesity has an effect on the lower extremity? Does childhood obesity cause flatfoot? What does the literature tell us about treating hypermobile flatfoot? What role should orthoses and shoes play in treating hypermobile flatfoot? Pediatric Flatfoot To Treat or Not to Treat Evans 2008 Method Meta-analysis of randomized controlled studies, separated by design Wenger 1989 - no difference Powell 2005 - significant improvement Whitford 2007 - mixed results Recommendations • Introduced patient-generated index • Established observations and assessment • Poor running, leg aches, shoe wear/comfort, angle of gait Obesity, heel eversion, tenderness, heel inversion with tiptoe Treatment pathway Red light -symptomaticÎ treat Yellow light -poor structure but developingÎ monitor for symptoms Green light –transient / improvingÎ leave alone Evans. AM: The flatfooted child—To treat or not to treat. JAPMA, 2008 Pediatric Flatfoot Orthotic Therapy Goals GOAL #1 Increase ground reactive forces medially GOAL #2 Provide stable surface in shoe GOAL #3 Improve calcaneal position on ground Orthotic Goal 1 Increase Ground Reactive Forces Medially Medial skive • Wide plate or medial flange • Increases supinatory moment Expand surface area under foot Rigid or semirigid plate • 3mm polypropylene for <50 lbs. Orthotic Goal 2 Provide Stable Surface in Shoe Semirigid or rigid device Rearfoot post Wide plate Orthotic Goal 3 Improve Calcaneal Position on Ground Deep heel cup • Rearfoot post • • Improves ground reactive forces in frontal plane on a higher level Increases contact area and rearfoot control Increases medial ground reactive force Medial Skive • 2-8 mm Pediatric Flatfoot Custom Orthotic Recommendations Material: Width: Heel Cup Height: Cast Fill: Positive Cast : Posting: Additions: 3mm polypropylene Wide and medial flange Deep (20+mm) Minimal 2-8 mm medial skive 0/0 (flat) Optional topcover for athletic shoes Pediatric Flatfoot Prefabricated Orthoses Advantages • • Cost Frequent foot size changes are easier to accommodate Disadvantages • • • Sizes limited Heel cup may not be deep enough for adequate control Medial skive not frequently incorporated Pediatric Flatfoot Prefabricated Orthotic Recommendations Specifications • • • • • • • • Close sizing Rigid poly 20+ mm heel cup Wide width Medial flange Medial skive Rearfoot post Sizing set Importance of Shoes Effects of torsional shoe flexibility on gait How do children learn to walk? Does shoe structure affect children’s gait patterns? Shoe Study 15 subjects • 5 cruisers: dependent walkers • 5 early walkers: walking for 0 – 5 months • 5 mature walkers: walking for 6 – 12 months 9 - 24 months of age 8 females, 7 males Obstacle Course Stumbles and Falls Plantar Distribution Results: Barefoot Interpretation H2: Footwear will affect the number of stumbles and falls when a child executes functional activities Number of Stumbles & Falls ( n=15 ) 14 12 10 Barefoot Softee 8 Jamie II 6 Adv Jamie A Adv Jamie B 4 2 0 Stumbles (n=15) Falls (n=15) Results: Plantar Distribution H5: Footwear will change plantar pressure distributions (peak pressures under each metatarsophalangeal joint and the medial and lateral aspects of the foot) Peak Pressure (N/cm2) (N=10) 12 10 1st MTPJ (right) 8 2nd MTPJ (right) 6 3rd MTPJ (right) 4th MTPJ (right) 4 5th MTPJ (right) 2 0 Jamie II Advanced Jamie Advanced Jamie B A Softee Summary Childhood obesity is a new link to flatfoot Evidence supports treating symptomatic and non-improving flatfoot with orthoses There are specific criteria for selecting prefabricated kiddy orthotics The flexibility of the shoe influences walking stability in children Numerous studies link obesity, LE trauma, pediatric flatfoot, and orthotic treatment “The verified change in foot morphology from childhood obesity may produce foot discomfort and... in-turn might keep children from being active and…therefore reinforce the risk of obesity” Mauch M, 2008 Inactivity Foot Discomfort Obesity Thank You
