PIGEON TOES, KNOCK KNEES,AND FLAT FEET:WHEN TO SEE THE ORTHOPAEDIC SURGEONI.M. Doctor, M.D.

My OfficeMy City, State

2

The information in this presentation was provided to the presenter by the

American Academy of Orthopaedic Surgeons and may be modified.

Endorsement of this presentation by the

AAOS is not implied or inferred.

Thank you to Members of the Pediatric Orthopaedic Society of North

Americafor contributions to the

content of this presentation.

3

What is an orthopaedic surgeon?

MD who specializes in treatment and health maintenance of musculoskeletal system (bones, joints, ligaments, muscles, tendons, cartilage and spine)

4

What is an orthopaedic surgeon?

The expert in treating the musculoskeletal system

The expert in maintaining musculoskeletal health

5

Educating an Orthopaedic Surgeon

College Medical School Internship Orthopaedic

Residency Fellowship (optional) 2 Years Practice

TOTAL

4414(1)2

16 years!16 years!

6

What do orthopaedic surgeons do?

Diagnose Treat

Medication Physical Therapy Exercise Brace Surgery

Prevent

7

What is a pediatric orthopaedic surgeon?

Orthopaedic surgeons who have chosen to make the core of their practice the care of children and adolescents who have musculoskeletal conditions

Typically have completed additional subspecialty training (fellowship) in pediatric orthopaedics

8

Why pediatric orthopaedics? Children are not just small adults

Bodies are still growing Responses to injuries and conditions are

different Communication skills, emotions and

cooperation are different

9

When is a pediatric orthopaedic surgeon the best choice?

For uncommon conditions When adult orthopaedic surgeons are

not comfortable with evaluation or treatment

When you have concerns that pediatric-focused orthopaedic care is needed

10

Pigeon Toes, Knock Knees,and Flat Feet

Feet turn out/in

Knock knees

Bow legs

Flat feet

Common conditions that are often normal:

11

What is normal? What is abnormal?

12

History

What is the specific concern? When does it manifest? Duration? Improving or worsening? Patient’s medical history and family

medical history

13

Who is concerned?

Parents Grandparents Pediatrician Teachers Others

14

In-toeing and Out-toeing

15

In-toeing

Common in babies and toddlers

Almost always resolves without treatment

16

In-toeing

Not painful in and of itself Not associated with early arthritis Can rarely be associated with knee

pain and problems

18

In-toeing: Causes

Metatarsus adductus – atypical twisting or bending of the foot

Tibial torsion – twisting of the shin bone (tibia)

Femoral antetorsion – twisting of the thigh bone (femur)

19

In-toeing: Metatarsus Adductus

Majority are flexible

Resolves by 3-4 years of age

10% stiff and may benefit from casting

20

In-toeing: Tibial torsion

Common in infants Usually resolves itself May be treated with

surgery in more serious cases

21

In-toeing: Femoral antetorsion

23

In-toeing: Treatment

No treatment necessary in most cases

Ongoing observation may be recommended

Surgery in some severe cases

24

Out-toeing

Toes pointing outward Less common than in-

toeing Caused by twisting of

hip, thigh, shin, or foot Unlikely to improve over

time, unless a result of flat feet

25

Out-toeing

Usually in normal range Usually causes no problems Rarely requires special care

26

Angular Problems

Knock-knees (genu valgum) Bow legs (genu varum)

27

Angular Problems

28

Angular Problems

Physiologic Pathologic

Trauma or injury Rickets Tibia vara (Blount’s disease) Skeletal dysplasia

29

Angular Problems

Age 2 Age 4

2 2+

4

34

35

Flatfoot

All infants have itMost children have itMore than 15% of adults have it

36

Flexible flatfoot

Often resolves with growth Not correlated with disability in military

populations Not affected by special shoes, inserts, or

braces

37

Stiff flatfoot on the right – does not correct on toe standing

Stiff flatfoot

38

More foot pathologies to consider

Clubfoot Calcaneovalgus

foot

39

Clubfoot

Incidence 1:1000 Boys > girls One or both feet

turned inward May sometimes be genetic

40

Clubfoot treatment

Serial manipulationsand casting

Begin first week of life, if possible

Perform weekly 90% of routine clubfoot respond

41

Calcaneovalgus foot

Most common foot deformity at birth

Foot points up Resolves

spontaneously Associated with hip

dysplasia

42

When do you need to see a pediatric orthopaedic surgeon?

Over three years of age with documented progression of deformity

Stiff metatarsus adductus

43

When do you need to see a pediatric orthopaedic surgeon?

Bowing below the 5th percentile for

height marked asymmetry

Marked knock-knees or in-toeing in patients over 8 years of age

44

American Academy of Orthopaedic Surgeons6300 North River Road

Rosemont, IL 60018

www.aaos.orgwww.Orthoinfo.org

Resources

45

What are your questions and concerns?

Pigeon Toes, Knock Knees, and Flat Feet

46

Thank you for participating today Remember, your orthopaedic surgeon can help get you

back in the game

Pigeon Toes, Knock Knees, and Flat Feet