Pediatric Obesity – The Foot Connection


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Pediatric obesity is growning out of control. Treatment of this very serious medical condition has a very low success rate. Why? Everyone has missed a critical part of the equation. Please read this presentation to learn more.

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Pediatric Obesity – The Foot Connection

  1. 1. Pediatric Obesity – The Foot Connection New Treatment Updates Michael E. Graham, DPM, FACFAS, FSPS, FAENS Macomb, Michigan
  2. 2. Childhood obesity is on the rise.
  3. 3.
  4. 4.
  5. 5. • Obesity leads to many other health problems• We have to eliminate obesity in order to treat these other diseases, otherwise the secondary health problems will continue to get worse, not better
  6. 6. Obesity TreatmentDid you know:• Only 21% of 64 obesity programs resulted in 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 intake is only part of the equation• We have to get these kids moving• This increases their metabolism
  9. 9. Exercise is important to maintaining proper body weight.Exercise leads to increased metabolism and decreased weight.
  10. 10. Sounds Good, BUT…What if they have bad feet?
  11. 11. Feet are the foundation to the body.
  12. 12. Stability of the hindfoot mechanism is critical for standing, walking, and running.
  13. 13. Bad Feet = Increased Pain = Decreased Exercise• Majority of obese children also have faulty foot mechanics (talotarsal dislocation)• Like driving your car with unbalanced, worn-out tires and with the steering out of alignment – it’s not fun
  14. 14. They Suffer When They Exercise• 4 to 5 times your body weight travels through each foot when walking and up to 10 times when running• When everything is aligned, this is still considerable force• But when talotarsal dislocation occurs: – 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 faulty mechanics in the foot will cause symptoms to develop throughout the rest of the body
  16. 16. TaloTarsal Dislocation Syndrome This translates to excessive motion that can potentially affect the Knee Pelvis Hips Lower Back Spine Neck Jaw (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 of alignment” the years of standing, walking and running are going to take their toll• Early on, don’t feel the ill-effects, but eventually the signs and symptoms will appear• Just like this car tire• It’s not IF, it’s 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 the stability of our feet• But how can we really do this?
  21. 21. TaloTarsal Dislocation• The dynamic displacement of the talus (ankle bone) 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 articular facets of the talus on the calcaneus and navicular• Four (4) articular contact points – Posterior, middle & anterior talocalcaneal – Talonavicular• Supination/pronation• There should be very little talotarsal motion
  23. 23. Hindfoot Alignment – TaloTarsal Mechanism
  24. 24. Radiographic Evaluation TaloTarsal Dislocation Lateral view • Talar declination > 26 degrees • Anterior deviated cyma line • Obliterated sinus tarsi • “Dropped" navicular NSP • Compare Neutral vs. Relaxed Stance Position • Sagittal plane dislocation deformity RSP
  25. 25. Radiographic Evaluation AP view • Talar 2nd metatarsal angle should be < 16 degrees • > 16 degrees = pathologic displacement
  26. 26. Pes PlanoValgus versus TaloTarsal Dislocation CIA* is flat to negative CIA is normal to increased Pes PlanoValgus TaloTarsal Dislocation*Calcaneal Inclination Angle
  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 to repeated destructive forces acting on the – Foot – Ankle – Knee – Hip – Pelvis – Back – Shoulders – Neck
  29. 29. Treatment Option- Observation• The feet don’t automatically fix themselves.• They progressively get worse.
  30. 30. Benefit – Risk Analysis Observation• Benefits: • Risks: – Non-surgical option – Progression of the disease – Relatively inexpensive process (still have to follow these – Every step is inefficient patients’ progress) – Excessive abnormal strain – Does not rely on patient on supporting soft tissue compliance structures – 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 complications
  31. 31. Treatment Option- Orthoses/Shoes• Do arch supports really work?• Where is the radiographic proof of realignment of the osseous 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 complications problems- increased pain – Patient compliance issues – Need new devices made regularly – Have to be worn in shoes
  33. 33. Treatment Option- Rearfoot Surgery
  34. 34. Benefit – Risk Analysis Rearfoot 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 the world ofExtra-Osseous TaloTarsal Stabilization
  36. 36. What is EOTTS?• The use of an internal device to prevent excessive motion of the talus on the calcaneus and navicular• Differentiated from – inter-osseous – intra-osseous• Purely a soft tissue procedure to improve the function of hindfoot mechanism
  37. 37. EOTTS Devices• Made of titanium• Not screwed into bone• Reversible• Performed on children as young as 3 and older• Tens of thousands have been performed Example EOTTS device
  38. 38. What can EOTTS Achieve?
  39. 39. What it can’t fix.It can’t fix everything, there are limitations. Have to have a flexible deformity, that isthe talus can be repositioned on the calcaneus. It will not increase CIA.
  40. 40. Who is a candidate for EOTTS• Must have a flexible deformity (talus can be repositioned on tarsal mechanism)• Three years of age or older (no upper age limit)
  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 plans
  43. 43. We have to stabilize their feet• EOTTS really is the best option• Do not have issues with patient compliance• There is supporting clinical & radiographic evidence of improvement• Reversible procedure
  44. 44. Conclusions• Talotarsal dislocation is not normal (sometimes seen in children as flatfoot/navicular drop)• There are better options now that are time tested and proven• It is a team approach• You have access to a great number of foot and ankle specialists who are here to do their best to keep our children active, healthy, and happy
  45. 45. Because at the end of the day, we are just trying our best to keep everyone walking.
  46. 46. Please visit for more valuable information and tofind a HyProCure specialist near you. ®