pediatric obesity – the foot connection

Pediatric Obesity – The Foot Connection New Treatment Updates Michael E. Graham, DPM, FACFAS, FSPS, FAENS Macomb, Michigan

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Post on 21-Aug-2015



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  1. 1. Pediatric Obesity The Foot ConnectionNew Treatment UpdatesMichael E. Graham, DPM, FACFAS, FSPS, FAENSMacomb, Michigan
  2. 2. Childhood obesity is on the
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  5. 5. Obesity leads to manyother health problems We have to eliminateobesity in order to treatthese other diseases,otherwise thesecondary healthproblems will continueto get worse, not better
  6. 6. Obesity TreatmentDid you know: Only 21% of 64 obesity programs resultedin a short-term weight-loss Of that 21%, it was only a small change WHY?
  7. 7. Obesity Treatment Decreased food intake Increase weightbearing activity Decrease sedentary behavior
  8. 8. Obesity Treatment Decreased food intakeis only part of theequation We have to get thesekids moving This increases
  9. 9. Exercise is important to maintainingproper body weight.Exercise leads to increased metabolismand decreased weight.
  10. 10. Sounds Good, BUTWhat if they have bad feet?
  11. 11. Feet are the foundation to the
  12. 12. Stability of the hindfoot mechanism iscritical for standing, walking, and running.
  13. 13. Bad Feet = Increased Pain = Decreased Exercise Majority of obese childrenalso have faulty footmechanics (talotarsaldislocation) Like driving your car withunbalanced, worn-out tiresand with the steering out ofalignment its not fun
  14. 14. They Suffer When They Exercise 4 to 5 times your body weighttravels through each foot whenwalking and up to 10 times whenrunning When everything is aligned, thisis still considerable force But when talotarsal dislocationoccurs: Muscles, tendons and ligaments have to compensate for the excessive, abnormal strain The soft tissues first have to bring the hindfoot bones back into normal alignment and then do their regular job to propel the foot
  15. 15. They Suffer When They Exercise Over time, the faultymechanics in the foot willcause symptoms to developthroughout the rest of thebody
  16. 16. TaloTarsal Dislocation Syndrome This translates to excessive motion that can potentially affect the Knee Pelvis Hips Lower Back Spine NeckJaw(far more than just the foot)
  17. 17. TaloTarsal Dislocation Syndrome Did you know the average person takes 7,000 steps/day 49,000 steps/week 196,000 steps/month 2,352,000 steps/yr 11,760,000 steps in 5 years 22,520,000 steps in 10 years 47,040,000 steps in 20 years 116,600,000 steps in 50 years
  18. 18. Think about it Even if our foot is slightly out ofalignment the years of standing,walking and running are going totake their toll Early on, dont feel the ill-effects,but eventually the signs andsymptoms will appear Just like this car tire Its not IF, its WHEN
  19. 19. Finally, most people will just give up Why keep torturing yourself? You are rewarded with pain.Increased activity = Increased painDecreased activity = Decreased pain
  20. 20. We have to stabilize their feet Brings us right back to thestability of our feet But how can we really dothis?
  21. 21. TaloTarsal Dislocation The dynamic displacement of the talus (anklebone) off the tarsal mechanism (hindfoot bones) Reducible/flexible: occurs when weight bearing(standing, walking, running) Results in excessive motion of the joint(hyperpronation) Leads to excessive forces on supporting tissues(tendons, muscles, ligaments)
  22. 22. TaloTarsal Mechanism Relationship of the articularfacets of the talus on thecalcaneus and navicular Four (4) articular contact points Posterior, middle & anterior talocalcaneal Talonavicular Supination/pronation There should be very littletalotarsal motion
  23. 23. Hindfoot Alignment TaloTarsal
  24. 24. Radiographic Evaluation TaloTarsal Dislocation Lateral view Talar declination > 26 degrees Anterior deviated cyma line Obliterated sinus tarsi Dropped" navicularNSP Compare Neutral vs. Relaxed Stance Position Sagittal plane dislocation
  25. 25. Radiographic Evaluation AP view Talar 2nd metatarsal angle should be < 16 degrees > 16 degrees = pathologic
  26. 26. Pes PlanoValgus versus TaloTarsal DislocationCIA* is flat to negative CIA is normal to increasedPes PlanoValgus TaloTarsal Dislocation*Calcaneal Inclination
  27. 27. Treatment Options Observation Arch supports/orthoses Special shoes or braces Rearfoot reconstruction surgery Extra-Osseous TaloTarsal Stabilization (EOTTS)
  28. 28. Treatment Option- Observation Every step leads torepeated destructiveforces acting on the Foot Ankle Knee Hip Pelvis Back Shoulders Neck
  29. 29. Treatment Option- Observation The feet dontautomatically fixthemselves. They progressively getworse.
  30. 30. Benefit Risk AnalysisObservation Benefits: Risks: Non-surgical option Progression of the disease Relatively inexpensiveprocess (still have to follow these Every step is inefficient patients progress) Excessive abnormal strain Does not rely on patienton supporting soft tissue compliancestructures No anesthesia/surgical Mal-alignment to other risks structures within the foot & ankle and also up the musculoskeletal chain Leads to the worst possible long-term
  31. 31. Treatment Option- Orthoses/Shoes Do arch supports reallywork? Where is theradiographic proof ofrealignment of theosseous structures?
  32. 32. Benefit Risk Analysis Orthoses/Shoes Benefits Risks Non-surgical option Not proven to decrease Relatively inexpensive tissue strain (compared to surgical Not proven to improve options) radiographic No potential measurements anesthesia/surgical Can lead to other complicationsproblems- increased pain Patient compliance issues Need new devices maderegularly Have to be worn in shoes
  33. 33. Treatment Option- Rearfoot
  34. 34. Benefit Risk AnalysisRearfoot Reconstructive Surgery Benefits: Risks: Radiographic correction Surgical risks Internal correction Non-union Infection Does not rely on patient Need for revision compliance Need to remove internal May be covered by hardware insurance companies Anesthesia risk (low) Expensive Long recovery
  35. 35. Now I would like to introduce you to theworld ofExtra-Osseous TaloTarsal
  36. 36. What is EOTTS? The use of an internaldevice to preventexcessive motion of thetalus on the calcaneusand navicular Differentiated from inter-osseous intra-osseous Purely a soft tissueprocedure to improve thefunction of hindfootmechanism
  37. 37. EOTTS Devices Made of titanium Not screwed into bone Reversible Performed on childrenas young as 3 and older Tens of thousands havebeen performedExample EOTTS
  38. 38. What can EOTTS Achieve?
  39. 39. What it cant fix.It cant fix everything, there are limitations. Have to have a flexible deformity, that isthe talus can be repositioned on the calcaneus. It will not increase
  40. 40. Who is a candidate for EOTTS Must have a flexibledeformity (talus can berepositioned on tarsalmechanism) Three years of age orolder (no upper agelimit)
  41. 41. Who is not a candidate for EOTTS Rigid deformity Less than three (3) years of age
  42. 42. Benefit Risk Analysis EOTTS Benefits: Risks: Internal solution Device displacement Minimally invasive, fast Over/Under-correction Extra-osseous Need for revision or (soft tissue) permanent removal Reversible Soft tissue adaptations Proven to decrease strain General surgical risks on supporting tissues Radiographic evidence Covered by most
  43. 43. We have to stabilize their feet EOTTS really is the bestoption Do not have issues withpatient compliance There is supporting clinical &radiographic evidence ofimprovement Reversible procedure
  44. 44. Conclusions Talotarsal dislocation is not normal (sometimes seenin children as flatfoot/navicular drop) There are better options now that are time testedand proven It is a team approach You have access to a great number of foot and anklespecialists who are here to do their best to keep ourchildren active, healthy, and happy
  45. 45. Because at the end of the day,we are just trying our bestto keep everyone walking.
  46. 46. Please visit for more valuable information and tofind a HyProCure specialist near you.