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Pediatric Foot Exam and Kids and Insoles: An Introduction to Orthotics

Pediatric Foot Exam and Kids and Insoles: An Introduction to Orthotics

by | Jan 7, 2022 | Research & Innovation

This is a summary of a lecture provided by Anthony I. Riccio, M.D., and Kelsey Thompson, C.P.O., L.P.O., as part of the series Coffee, Kids and Orthopedics for medical professionals.

You can watch the full lecture and print the pdf.Pediatric Foot Exam

Anthony I. Riccio, M.D.

Assessment of Rotational Deformity

Foot Progression Angle

The initial phase of the foot exam is to get an understanding of the child’s foot progression angle. Foot progression angle refers to how the foot lies in relationship to a line projected directly in front of the foot. The angle can be affected by the structures in the foot itself and/or by rotational differences in the hip, the leg or within the foot. The angle can also be affected by how the foot strikes the ground during walking.

Gait Assessment of Foot Progression Angle
Imagine a line projected directly in front of the patient.

  • Neutral: Patient’s feet are parallel to that line as they take steps.
  • ​​External: Patient’s feet are turned externally or away from that line.
    • Sometimes referred to as a “duck walk” by parents.
  • Internal: Patient’s toes are turned towards this line.
    • Sometimes referred to as “pigeon-toeing.”

Though the foot progression angle might be perceived as abnormal by the parent, it is more important to look for a pathologic situation that might be responsible for it. If a patient has a foot progression angle that doesn’t seem normal, you want to see if that deviation is coming from an extremity more proximal to the foot.

Supine and Prone Assessment of Femoral Version
We typically start by assessing rotational profiles of the hip to see if there is any excessive internal or external rotation deformity that might be contributing to the way the foot rests against the ground as the child takes a step.

Supine Assessment

  1. Flex the hip and knee to 90° maintaining neutral rotation.
  2. ​Internally rotate the hip (which will externally rotate the leg in relation to the thigh).
  3. Estimate the angle of internal rotation.
  4. Externally rotate the hip (which brings the leg inward relative to the thigh).
  5. Estimate the angle of external rotation.
  6. Compare to contralateral.

Prone Assessment

  1. With hips extended, flex knees to 90°.
  2. ​Assess internal and external rotation of the hips.
  3. Estimate the angle between the leg and the table.

Assessment of Tibial Torsion
Tibial torsion, or rotation, may contribute to an abnormal foot progression angle.

Prone Assessment

  1. Flex the knee to 90°.
  2. ​Visualize or draw a line directly down the axis of the patient’s foot.
  3. Visualize or draw a line directly down the axis of the patient’s thigh.
  4. Assess the angle between those two lines.
    • If they are perfectly colinear, the angle is 0°.

Supine Assessment

  1. With hip and knee extended, rotate the hip until the kneecap points straight up in the air.​
    • ​This takes removes rotational differences in the hips to assess rotation in the lower leg.
  2. Estimate the angle of the feet in relation to the plane of the table.

Assessment of Metatarsus Adductus
Sometimes a foot deformity is causing the patient’s internal foot progression angle. The most common is metatarsus adductus, in which there is an internal rotation of the foot itself. These feet are normal structurally on the inside, but they were molded into somewhat of an internally angulated position during intrauterine gestation.

Prone Assessment

  1. Draw or visualize a line straight up the axis of the heel.
  2. Project that line distally to get an understanding of where the second toe lies in relationship to that line with the ankle in a neutral position.
    • As the foot turns more inward, this line will then intercept the third toe, the fourth toe, the fifth toe or no toes at all.

Examination of the Foot
Assessment of Standing Alignment of the Midfoot and Hindfoot
Standing Assessment – Anterior View

  • Assess the position of the foot in relationship to the tibia and the hips.
  • ​Assess what the midfoot and forefoot are doing in relationship to the hindfoot.

Standing Assessment – Posterior View

  • Assess the position of the calcaneus or heel bone in relationship to the Achilles.
  • Draw or visualize a line directly down the Achilles tendon.
  • Draw or visualize a line directly down the axis of the posterior tuberosity of the calcaneus.
  • Assess those lines to see if they are relatively collinear.
    • In a severe planovalgus or flatfoot deformity, the heel axis would be positioned very far externally, in relationship to the Achilles.

    • In a cavovarus foot deformity, say in the setting of Charcot-Marie-Tooth disease, that calcaneal axis would be turned inward significantly in relationship to the axis of the Achilles.

To get a sense of how turned out the midfoot is in relationship to the hindfoot, assess how many of the patient’s lateral digits you can see lateral to the heel bone:

Standing Assessment – Posterior View

  • It is normal to see the 5th toe and part of the 4th toe on both sides.
  • Seeing the third toe and the 4th toe means the midfoot rotated out.
    • This is typically seen with a flatfoot deformity.
  • If you can’t see the small toe, the midfoot is rotated inward.
    • This is seen with metatarsus adductus or in cavovarus deformities seen in children with peripheral neuropothies.

Assessment of Subtalar Motion
Toe Rise Test
The subtalar joint includes the talus, also called the “ankle bone,” and the calcaneus. This is where the heel either turns outward in a valgus deformity, like a flatfoot, or inward such as in a cavovarus deformity associated with peripheral neuropathy.

Visualizing the foot from behind helps you assess flexibility, especially in the presence of a flatfoot deformity. You can get a sense of subtalar motion by whether or not the angle between the axis of the posterior tuberosity of the calcaneus and the Achilles changes as the child goes from a standing flat position to standing up on their toes.

Standing Assessment – Toe Rise Test

  • Visualize the axis between the Achilles and the posterior tuberosity of the calcaneus is in standing.
  • ​Observe the axis as the patient elevates “way up” on their toes.
  • If the heels turn inward in relation to the Achilles into a varus position, it indicates flexibility in the subtalar joint. This joint is called the subtalar joint, and it is the joint through which the heel either turns outward in a valgus deformity, like a flatfoot, or inward such as in a cavovarus deformity associated with peripheral neuropathy.

Coleman Block Test
A classic test used to assess subtalar motion, which is really for children with a cavovarus foot deformity is the Coleman Block Test. This test is designed to assess flexibility through the subtalar joint in a patient who has their heel turned inward and helps discern whether or not that turning in is due to inflexibly in a fixed deformity through the subtalar joint, or if it is simply a result of the first ray striking the ground before the 5th ray, and forcing the heel to angulate inward as a result of a very high arched foot.

Standing Assessment – Coleman Block Test

  1. Assess the angle between the Achilles tendon and the posterior tuberosity of the calcaneus.
  2. Have the child to lift their foot up.
  3. Place a small block just under the lateral aspect of the forefoot.
  4. Ask the patient to put all their weight down on the foot.
    • This drops their big toe so you see what happens to their hindfoot.
      • If the heel does not turn into a more valgus position, it indicates a rigid subtalar joint which could be a varus deformity.

Table-Top Testing of Ankle and Subtalar Motion
The ankle joint, made up of the talus, tibia and fibula bones, is designed to flex and extend only. Side-to-side motion comes from the subtalar joint. An inability to move the subtalar joint might be indicative of an abnormal bony connection either between the heel bone and the ankle bone or between the heel bone and the navicular bone, which are termed tarsal coalitions. These are typically seen in a rigid flat foot deformity.

Seated Assessment

  1. Bring the ankle joint up into maximal dorsiflexion.​​
    • It also allows you to isolate the subtalar joint.
    • ​This locks the widest part of the ankle joint into the ankle mortis to prevent any inadvertent motion though the ankle joint.
  2. ​Grab the heel on either side both medially and laterally.
  3. Move it inward (supinate) and outward (pronate).
    • If the foot will turn in and turn out, it indicates excellent motion through that joint.

Vascular Assessment

  • Assess the tibial artery pulse which lies directly posterior to the medial malleolus.
  • ​Assess the dorsalis pedis pulse just a few centimeters proximal to the first dorsal web space.

Plantar Skin Assessment

  • Calluses on the outside of the foot are frequently indicative of lateral column overload.
  • This is seen in children with residual clubfoot deformities, or in cavovarus foot deformities.
  • Calluses on the medial border of the foot are seen in children with flatfoot deformities.

The Silverskiold Test for Achilles Contracture / Gastrocnemius Tightness
One of the most important parts of a foot and ankle exam is understanding tightness of the Achilles tendon, the gastrocnemius muscle or the gastric-soleus complex. The Achilles tendon is derived from two muscle groups: the gastroc muscles and the deeper soleus muscle. Children with flat foot deformities or who walk on their toes often have tightness in one or both of those two muscle groups. To differentiate between tightness in the gastrocnemius or tightness in both the gastrocnemius and the soleus, we perform what is called the Silverskiold test which assesses passive dorsiflexion of the ankle with the heel held in an internally rotated position.

Supine Assessment – The Silverskiold Test

  1. Bring the Achilles out to maximal length by turning the heel in.
  2. Grab the heel while supporting the rest of the foot with your wrist and the lower part of your forearm.
  3. Keep the knee extended to keep the gastrocnemius muscle as tensioned as possible at the knee.
  4. Assess passive ankle dorsiflexion.
  5. Document the difference between neutral dorsiflexion, which is 90°, to the leg to get your baseline assessment.
  6. Then bend the knee to relax the gastroc muscles.
  7. See how much more you can dorsiflex the foot.
    • The gastroc muscles are usually much tighter than the soleus.
      • If there was no difference, in the amount of passive dorsiflexion with her knee extended and the gastrocs on stretch and then the flexed, then the tightness would be a result of combined issues with both the gastroc and the soleus complex.

This not only helps in surgical decision making, but it can help clinically with regards to deciding how we are going to stretch out children with tight heel cords.

Assessment of Ankle Instability (The Anterior Drawer Test)
Ankle instability is common in relatively older kids, especially those who have had multiple ankle sprains. In order to test for ankle instability, we first have to understand the ligamentous anatomy on the lateral side of the ankle. Those two ligaments are both attached to the lateral malleolus, or the fibular bone.

  • The anterior talofibular ligament (ATFL) is the more anterior of the two and connects the fibula to the talus (ankle bone).
  • ​The calcaneofibular ligament (CFL) is the more posterior of those two and connects the fibula to the heel bone.

To test for stability, individually assess the function of each of these ligaments with an anterior drawer test.

Seated Assessment – Anterior Drawer Test in dorsiflexion and plantarflexion
Dorsiflexion places the CFL on maximum stretch and plantarflexion places the ATFL on maximum stretch.

  1. Cup the heel.
  2. Grab the ankle bone with your thumb while supporting the tibia.
  3. Bring the ankle into dorsiflexion. *
  4. Pull forward on the foot and the heel bone while pushing back on the tibia or leg bone.
    • See if there is excessive anterior translation through the ankle joint.

* Repeat the test but with the ankle in maximum plantarflexion.

Children without connective tissue disorders will only have ankle instability on one side, typically due to multiple injuries and sprains. Always compare the amount of translation from the bothersome ankle to the normal ankle to assess for any difference.

Assessment of Anterior and Posterior Ankle Impingement
An anterior ankle impingement is typically the result of a dysmorphology of the ankle joint, typically the talus. We see this frequently in children who have had prior interarticular surgeries, particularly those with clubfeet. Their ankle, which is supposed to be a relatively rounded joint becomes more flattened and can’t roll under the tibia bone. Instead it’s flat and as they try to advance the tibia over their foot in walking, the front of the ankle bone bumps and bangs into the front of the tibia bone.

Seated Assessment – Anterior Ankle Impingement

  1. Palpate for tenderness around the anterior aspect of the ankle.
  2. ​Perform forceful maximal dorsiflexion to see if that forceful abutment of the talus into the tibia reproduces anterior ankle pain.

With posterior ankle impingement, some children will have an os trigonum which is normal ossification (bone growth) behind the talus bone. The vast majority of these are completely asymptomatic, but occasionally it can be large enough or the child can be active enough that the ossicle will bang against the back of the ankle during points of maximal plantarflexion. This is commonly seen in gymnastics and dancers who spend a lot of time up on their toes. Because they are repeatedly, maximally plantarflexing their ankle, they can force the ossicle into the posterior aspect of the joint which can create pain.

Seated Assessment – Posterior Ankle Impingement

  1. Palpate for tenderness around the posterior aspect of the ankle.
  2. Forcefully plantarflex the ankle to see if we can reproduce posterior ankle pain.

Assessment for Overuse Conditions
Sever’s Disease
Calcaneal apophysitis, or Sever’s disease, is a type of overuse injury caused by repetitive movements. It is the most common cause of heel pain in active children ages 8-12. This is often seen with tightness in the gastrocnemius, and the growth plate, the calcaneal apophysis becomes inflamed.

Seated Assessment – Palpation of the Calcaneal Apophysis

  1. Examine the insertion of the Achilles tendon in the area of the calcaneal tuberosity.
  2. Slide your thumb off the very back of the heel.
    • Approximately 1 – 1.5 centimeters forward.
  3. Push and squeeze on both the inside and outside of the calcaneal tuberosity, this will reproduce the pain in children with Sever’s disease.

Plantar Fasciitis

More often seen in adults, children and adolescents may also experience this tightness and pain on the plantar aspect of the foot. Oftentimes it doesn’t stop a child from doing the activities they want to do, but it becomes bothersome after they’ve stopped their activities and sit down or are taking a car ride or get out of bed first thing in the morning.
Perform a Silverskiold test to assess plantar fasciitis because it is directly linked to tightness of the gastroc soleus complex.

  • Take the big toe and dorsiflex it as much as possible.
  • This puts the plantar fascia on stretch because of some attachments to the flexor of the big toe.

Often passively dorsiflexing or extending that big toe will be enough to set these children off if they have a fasciitis in this area. If not, it certainly allows us to really get a sense of how tight that plantar fascia is and directly palpate it to see if it is painful for the child.

Kids and Insoles: An Introduction to Orthotics

Kelsey Thompson C.P.O., L.P.O.

Orthotist Perspective
What should you look at first?

  • Look at what shoes the patient presents with.Are they supportive shoes or flexible/non-supportive shoes?
  • Ask if those are the most commonly worn shoes, or if they have others.
  • Ask when the patient has pain.
    • With shoes, barefoot, all the time?
    • Do any shoes make their pain improve?
    • Have they tried better shoes or any off the shelf insoles?
    • If so, what have they tried?

Shopping for Shoes
Proper sizing is important.

  • The quality of shoes is better in adult sizes versus kids’ sizes.
  • ​Kids shoes are sized off Men’s sizes.
  • 5Y is a 6.5 Women’s, so girls can get into women’s shoes quicker than boys.
  • Women’s – B width, Men’s – D width.

Price

  • Price can be directly related to quality but not when it comes to popularity.
  • Related to quality of cushioning and how long shoe will last, not support.
  • Number of miles and still have the same amount of cushioning.

Where to Shop

  • Specialty running shoe stores (Run On, Frisco Running club, etc.) are recommended.
    • Can get past year models online for less.

Adding Support

  • Arch support needs to come from an insole bought separately.
  • A severe pronator needs motion control or stability shoeDenser midsole material on medial side of shoe.
    • Offered by Asics, Brooks and New Balance Shoes.

Physical Examination and Assessment

  • Ask the patient to walk barefooted.
    • Look for midfoot collapse, pronation, supination or rotation.
    • Check ankle ROM in subtalar neutral vs maximum.
      • Most of the time their calves are tight especially when in subtalar neutral.
  • Ask if they were given a home exercise program (HEP). If so, reinforce the instructions that they should follow.
  • Encourage them to stretch.

Determine Correctable or Rigid Deformity
Correctable Deformity

  • A correctible deformity can be treated with off-the-shelf insoles.
    • These are made off a generic model.
    • You want to look for one with actual support not one that is just a cushion.
    • You will need to purchase one size up and trim to fit the entire arch.
  • Recommended brands:
    • Superfeet, Spenco, New Balance, KidSole.
  • Recommended stores:
    • Run On, Dick’s Sporting Goods, Academy Sports + Outdoors, REI.

Sometimes customized off-the-shelf insoles are needed. These are made off a generic model but they are made with materials that can be modified This gives us the ability to adjust as necessary.
Off-the-shelf inserts are great for someone with a flexible flat foot. This means their foot can be fully corrected to have a good arch, but their arch collapses when bearing weight. The insole will support their arch.

Rigid Deformity
A rigid deformity will require custom foot orthoses.

  • Made from a foam impression or cast.
  • ​Takes 2-3 weeks for fabrication.
  • Requires a little more room in shoe than off-the-shelf.
  • A variety of materials available to fit patient’s needs.
    • Foams and plastics.
    • Cast and Impressions.

Custom orthotics are for patients with a fixed foot position where the arch is fully collapsed to the point that their navicular is almost dropped to the ground and they cannot be corrected.

About the Speakers
Anthony I. Riccio, M.D., is a pediatric orthopedic surgeon and the director of the Center for Excellence in Foot at Scottish Rite for Children. He specializes in clubfoot & other foot disorders and limb lengthening & reconstruction. He sees patients at our Dallas campus.

Kelsey Thompson C.P.O., L.P.O., is a certified prosthetist orthotist at the Scottish Rite for Children Orthopedic and Sports Medicine Center in Frisco. She studied biomechanical engineering at Texas A&M and trained in prosthetics and orthotics at UT Southwestern in Dallas where she also completed a residency in prosthetics and orthotics.

Stress Fractures in the Spine: Spondylolysis

Stress Fractures in the Spine: Spondylolysis

by | Dec 7, 2021 | Research & Innovation

Pediatric orthopedic surgeon Jaysson T. Brooks, M.D., presented this as part of Coffee, Kids and Orthopedics education series. Brooks provided a detailed discussion of evaluating stress fractures in the spines of adolescents.

You can  and print the pdf.

watch the full lecture -What is Spondylolysis?

The facet joints in the back of the spine are connected by small segments of bone called pars interarticularis. Since this portion of the spine doesn’t get a great blood supply, it is at risk for stress fractures. This condition is called spondylolysis. Spondylolysis occurs more commonly at the L5 level and less commonly at the L4 level.

Most kids aren’t born with spondylolysis; it is caused by overuse and repetitive mechanical stress or forces. Activities or sports with repetitive hyperextension can cause a stress fracture of the spine. We see a higher incidence of spondylolysis in adolescents – as many as 47% of those with back pain. This is typically higher during growth spurts. The condition is much less frequent in adults. Some estimate 5% of adults with low back pain have spondylolysis.

In some cases, the stress fracture occurs bilaterally and the vertebra can slip forward, which is called spondylolisthesis. If a slipped vertebra presses on a nerve, it might cause severe shooting pain down the leg, and surgery may be required. However, if it breaks and doesn’t slip forward, surgery might not be necessary.

Spondylolysis: Genetic Predisposition?

  • Spondylolysis occurs in 15-70% of first-degree relatives
  • Prevalence
    • White: 6%
    • Black: 2-3%
    • Indigenous American (Inuit): as high as 40%

History Matters

There is a higher prevalence of spondylolysis in elite athletes who report playing sports with repetitive hyperextension/rotation of the lumbar spine. Back pain should raise suspicion in these athletes:

  • Football lineman
  • Cheerleaders
  • Gymnasts
  • Weightlifters
  • Divers / Swimmers

Back pain without a history of injury or repetitive activities is less likely to be caused by a stress fracture. In cases with shooting or decentralized pain, disc herniation should be considered.

Exam

The physical exam to assess for a stress fracture begins with palpation, and pain should be centralized around L5-S1 area. Active extension and hyperextension will be more painful than flexion. Coordination and strength should not be affected unless there is some nerve involvement, but pain may impact their ability to perform activities like heel walking and single leg hopping.

Imaging

In most cases, especially if the patient heard a “pop” and has acute low back pain, a standing anterior-posterior (AP) and lateral X-ray of the lower lumbar spine is recommended.

A study published in the Journal of Pediatric Orthopaedics looked at 2,846 patients with a median age of 14.6 years that were seen for back pain. 76% had no clear cause for their back pain, and less than 61% had two or fewer follow-up visits. This is a good reminder that not every patient with back pain has a stress fracture.
X-rays may not show early signs of spondylolysis. Rather than automatically ordering advanced imaging, a pediatric sports or spine referral may be the best next step because MRIs may also be inconclusive.

Treatment

Treat conservatively first.

  • Activity Modification: 3 – 6 months
  • Physical Therapy: 3 – 6 months
    • Focus on core strengthening to improve lumbar stability
  • Non-steroidal anti-inflammatory drugs (NSAIDS)
    • Meloxicam and/or diclofenac cream
    • Naproxen
  • Bracing may provide comfort but does not affect return to activities.

Often patients only want to do one of these, but that may make extend their recovery by several months.
It is acceptable if a fracture never heals on an X-ray as long as the symptoms go away. If six months of conservative treatments only show slight improvements, a pars injection may help their symptoms. Some patients are injected every six months.

Surgery should always be a last resort.
If the gap is not too wide, a screw is used for a direct pars interarticularis repair. A fusion of the surrounding vertebra may be considered if a loss of motion is acceptable.

Check out our latest on-demand lectures available for medical professionals.

Experts Share Research at National Conference

Experts Share Research at National Conference

by | Oct 15, 2021 | Research & Innovation

As an institution dedicated to providing the best care to kids, experts from Scottish Rite for Children are involved with various medical organizations that support education and research. Recently, the American Academy of Pediatrics (AAP) held its virtual national conference and exhibition. AAP is an organization with more than 67,000 pediatricians who are committed to the health and wellness of all infants, children, adolescents and young adults. Our team at Scottish Rite has an active role with AAP as they share their expertise on caring for children with orthopedic conditions and regularly serve as a resource to pediatricians and their patients.

The 2021 virtual meeting provided attendees with a well-rounded educational program that included live presentations, a virtual hall of selected poster projects and a library of on-demand sessions. Topics covered all areas of caring for children, and during a session on pediatric orthopedics, several Scottish Rite experts were selected to present their latest research. Below are a few of the presented projects:
Hip

  • Isolated Hip Click and Developmental Dysplasia of the Hip

Sports Medicine

  • An Activity Scale for All Youth Athletes? An Analysis of the HSS Pedi-fABS in 2,274 Pediatric Sports Medicine Patients
  • Are There Differences in Reported Symptoms and Outcomes Between Pediatric Patients With and Without Obsessive Compulsive Disorder After a Concussion?
  • Are there Differences in Concussion-Related Characteristics and Return-to-Play in Soccer Positions?
  • Predictors of Reoperation in Adolescents Undergoing Hip Preservation Surgery for Femoroacetabular Impingement
  • Isolated Hip Click and Developmental Dysplasia of the Hip
  • History of Anxiety Associated with Head CT Following Sport-Related Concussion
  • Single-Sport Athletes Not Experiencing Increase in Secondary Tear Incidence Despite Earlier Clearance

Learn more about our research. 

Infants and Developmental Dysplasia of the Hip

Infants and Developmental Dysplasia of the Hip

by | Oct 7, 2021 | Research & Innovation

This article was originally published in the Pediatric Society of Greater Dallas newsletter. Committed to improving orthopedics care of pediatric patients in all settings, Scottish Rite for Children specialists are regular contributors to this publication for local pediatricians in North Texas.

Developmental dysplasia of the hip (DDH) is the most common orthopedic condition affecting newborns. The overall incidence has been estimated at approximately 1%. Dysplasia is a term that means poorly formed. It describes this condition well because one or both sides of the hip joint do not grow correctly as the child develops. In severe forms of DDH, the hip joint can be completely dislocated, meaning that there is no contact between the ball of the hip joint (femur) and the socket (acetabulum). 

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Screening for DDH
The American Academy of Pediatrics (AAP) published a clinical report on current standards for evaluating and treating DDH. With later recognition of the condition, the treatment becomes more complex and may even require surgery. In order to minimize missed cases of hip dysplasia, the AAP recommends that pediatricians periodically screen for DDH during routine office visits, from infancy until the child is walking. With effective screening, most cases are identified and managed during infancy, leading to complete correction of hip dysplasia and the development of normal hips.

Ann,-Hip.jpg

As a pediatric orthopedic surgeon, Corey S. Gill, M.D., M.A., cares for many children with DDH and has received several questions from referring providers about appropriate care. The most important things for pediatricians and other referring providers to understand about DDH include:

  • Perform a hip examination on every newborn and infant patient. Soft tissue clicks around the hip and knee are very common and do not generally indicate hip dysplasia. Similarly, asymmetric skin creases on the inner thigh do not usually mean there is a problem with the hip. Findings that are clearly abnormal and should lead to orthopedic referral include:
    • An unstable hip that “clunks” into or out of place. Hip stability is evaluated during the exam by performing the Barlow and Ortolani maneuvers. The Barlow test identifies a hip that is in place but can be easily dislocated with gentle pressure. The Ortolani test identifies a hip that is dislocated at rest, but can be placed back into the joint with positioning of the thigh.
    • Significantly decreased or asymmetric range of motion. This is especially important for abduction of the hips, which is moving the hips out to the side when lying down. Differences as small as 10 degrees compared to the normal side may indicate a significant problem.
    • A significant leg length difference, which may indicate a hip dislocation. Leg length difference is best evaluated with a Galeazzi test. This test is performed by flexing the hips to 90 degrees and checking to see if the knees are level.
    • In toddlers and older children, decreased hip abduction and a waddling gait, limp or unilateral toe walking may indicate hip dysplasia or dislocation.
  • Identify the risk factors that make hip dysplasia more likely. The two most important are family history of hip dysplasia and breech presentation (especially frank breech). Providers should have a low threshold for orthopedic referral in these patients. Other risk factors include female sex, first born child and oligohydramnios.
  • Understand the right time to refer a patient for DDH evaluation. In newborns with unstable hips on exam, a referral should be made immediately so treatment can start as soon as possible. In children with a normal exam but risk factors for DDH, an ultrasound should be obtained at approximately six weeks of age. Obtaining an ultrasound in children earlier than this often leads to a false positive diagnosis of DDH secondary to physiologic immaturity of the hip joint in the newborn.

Orthopedic Intervention

When infants do need orthopedic intervention for hip dysplasia, our first line of treatment is a Pavlik harness. This fabric and Velcro harness is generally worn for 23 hours per day for approximately six to eight weeks, but it is removable for bathing. The harness keeps the hips flexed and rotated in the correct position for normal development of the hip joint. After treatment with a Pavlik harness, we use physical exams, ultrasound and X-rays to monitor growth and confirm the hip joint is developing normally. Most infants with DDH require no further orthopedic treatment after wearing a Pavlik harness.

In some infants, especially those with severe hip dysplasia or a dislocation, Pavlik harness treatment may not be successful. Occasionally, a different type of hard plastic brace may be successful in correcting the hip dysplasia in these children. However, most children who do not respond to Pavlik harness treatment will ultimately require surgical intervention to prevent long term problems from hip dysplasia such as cartilage injury, limp, leg length difference and early arthritis. Depending on the severity of the hip dysplasia, surgical treatments may include:

  • Closed reduction – This involves repositioning the ball of the hip joint deeply into the socket when the child is asleep under anesthesia and then applying a body cast called a spica cast for a total of three to four months. During this procedure, we often inject a small amount of medical dye into the hip joint to confirm that the ball of the hip joint is appropriately positioned in the socket. This is called an arthrogram.
  • Open reduction – Sometimes the hip joint will not line up well with repositioning of the leg because there are tight tissues blocking the ball from sitting deeply in the socket. In these cases, an incision is made in front of the hip where the tight tendons, ligaments and soft tissues are moved out of the way. Afterwards, the lining of the hip joint is tightened with a strong suture to help hold the hip in position. This procedure is called a capsulorrhaphy.
  • Osteotomies – In older children (over age 1.5 – 2 years), soft tissue procedures alone are often not enough to ensure the hip joint is lined up well. In these cases, we often supplement the open reduction procedure by cutting the bone in a controlled way to help reorient the hip into the socket. This is called an osteotomy and can be performed on the ball side of the hip (femur osteotomy) or socket side of the hip (pelvic osteotomy). Metal implants are often used to hold the bone in the new position and are removed at a later date.

Conclusion

Hip dysplasia is a common orthopedic condition in newborns that can lead to significant long-term consequences if left untreated. Certain risk factors such as family history of dysplasia and frank breech presentation greatly increase the risk of developing DDH. Pediatricians play a crucial role in examining infants, identifying those with risk factors and referring them to a pediatric orthopedic specialist when appropriate. When diagnosed in the first few months of life, noninvasive treatment with a harness or brace is highly successful and generally leads to the development of a normal hip. In some cases of severe hip dysplasia/dislocation or in cases of delayed diagnosis, surgical intervention is required to improve the long term prognosis of the hip joint.

Referral Tips 

A potential diagnosis of hip dysplasia can lead to significant anxiety for new parents. Understanding the best time to refer patients and initiate treatment helps to maximize treatment success and efficiency while minimizing parental stress and worry.

  • For infants with risk factors for DDH such as family history or breech presentation but a normal physical exam, an ultrasound should be obtained around six weeks of age. Ultrasounds performed earlier than this age result in a large number of false positives and potential unnecessary treatment in a harness.
  • There is no need to obtain an ultrasound prior to referral as we work closely with experienced ultrasound technologists who can perform the diagnostic hip ultrasound on the same day as an infant’s office visit.
  • In children with a clearly abnormal exam (unstable/dislocatable hip or asymmetric hip abduction) in the nursery or in routine office visits, immediate referral should be made so that treatment in a harness can be initiated as soon as possible. In these children, there is no need to wait until the child is 6 weeks of age for referral.
  • If only abnormal exam finding is a “hip click” or asymmetric thigh crease, referral and ultrasound should be deferred until 6 weeks of age given the relatively low prevalence of DDH in these children.
  • In premature infants still in the NICU with risk factors for DDH, it is generally OK to wait for referral until after the child is discharged to go home. If an examiner finds the hip to be unstable while still an inpatient, phone consultation with a pediatric orthopedic surgeon is available to answer questions or discuss the most appropriate time to see the patient.
  • If a family has an infant diagnosed with DDH, all future siblings of the child should be referred for screening, ultrasound at six weeks of age and strong consideration should be given for referral of older siblings for a hip radiograph. First degree relatives have more than a tenfold higher risk of DDH compared to controls.
Sports Medicine Team Presents Latest Studies at National Meeting for Clinical Research Professionals

Sports Medicine Team Presents Latest Studies at National Meeting for Clinical Research Professionals

by | Sep 27, 2021 | Research & Innovation

The Society of Clinical Research Associates (SOCRA) is an organization committed to the education and certification of people involved in clinical research. Scottish Rite for Children has many research coordinators who participate in SOCRA and its activities. “We are fortunate to have individuals who are committed to ethical and meaningful research,” says Henry B. Ellis, M.D., pediatric orthopedic surgeon and associate director of clinical research. “Their membership and active participation in professional organizations like SOCRA bring value to our teams and work products.” While collaborating with others in study development and enrollment, data collection and manuscript preparation, research coordinators at Scottish Rite are encouraged to perform original research, publish and seek opportunities to share with appropriate audiences. This month, two research coordinators from our Sports Medicine team shared their work at the SOCRA annual meeting. Clinical research personnel from across the country participated in virtual continuing education opportunities, including digital poster presentations. “Posters are a traditional way of sharing an overview of a project and stimulating conversations among peers,” explains research coordinator Hannah M. Worrall, M.P.H., CCRP. “Even before the pandemic, we saw a shift to sharing them digitally, in place of or in addition to a traditional poster exhibit in a large hall.” All three posters were selected as finalists for the top clinical trial posters. Soccer-Related Concussions and Position Played The prospective study, “Differences in Concussion-Related Characteristics and Return-to-Play in Soccer Positions,” addresses a question about the influence of position-played on injury-related details and outcomes after a sport-related concussion. The data was prospectively collected from participants enrolled in the North Texas Concussion Registry (ConTex) from August 2015 to April 2021. This data has strong representation from patients seen in the Scottish Rite sports medicine clinic, so it is helpful to our team to continually improve care for this population. “In this study of almost 300 soccer players, goalkeepers showed higher rates of depression, disproportionately suffered more concussions and experienced a different mechanism of injury as well as had the lowest rate of returning-to-play three months after their injury,” says Worrall. This information may aid providers in educating players, their families and their coaches about the risks of concussion with different soccer positions and may play a future role in injury prevention. Investigators of this study include Hannah M. Worrall, M.P.H., CCRP, Claire E. Althoff, BA, Shane M. Miller, M.D., Jane S. Chung, M.D., Mathew A. Stokes, M.D., Stephanie Tow, M.D., C. Munro Cullum, Ph.D., and Jacob C. Jones, M.D.
Early Specialization The prospective study, “Sport Participation and Specialization Characteristics in a Pediatric Sports Medicine Clinic,” evaluated sport-related variables of more than 10,000 patients seen in our sports medicine clinic (2016-2021) with a specific set of questions in mind. The concepts of overuse and overtraining in youth sports have gained a lot of attention over the past decade because they lead to an increased risk of injuries.

SURVEY OF 10,000 PATIENTS MORE hours/week than age in years 15%. A pie chart that says survey of 10,000 patients more hours / week than age in years

A guideline has been proposed to reduce the risk of injury by limiting the number of training hours per week to the athlete’s age in years. For example, a 7 year old should not train more than seven hours/week in organized sports. The study found that 15% of athletes seen in the clinic did participate in more hours per week than their age. These athletes were more likely to report they are single-sport athletes, which is also known to increase their risk of injury. 

“The results support a growing body of evidence describing the risk of early specialization and overuse in youth sports,” says research coordinator Savannah Cooper, M.S., CCRP. “The effort should help guide continued education efforts for coaches, parents, administrators for youth sports and medical professionals.”

Investigators of this study include Hannah M. Worrall, M.P.H., CCRP, Savannah Cooper, M.S., CCRP, Jacob C. Jones, M.D., Shane M. Miller, M.D., and Jane S. Chung, M.D.

Standardized Postoperative Pain Management Opioid prescriptions following surgery in the adolescent population contribute to the use and abuse of addictive drugs in this age group. The purpose of this prospective study is to evaluate pain and opioid use following standardized surgeries in our patient population. The Scottish Rite for Children pediatric orthopedic surgery teams who care for joint-related injuries collaborated with pediatric anesthesiologists to implement a standardized pain management protocol for common surgical procedures with the goal of decreasing the number of opioid pills prescribed.

Plan Do Act Check. A diagram showing the steps of plan do act and check

“By using questionnaires to monitor pain level and pill usage, we are evaluating the effectiveness of the multidisciplinary and multi-modal protocol and looking at factors such as procedure type to determine areas for future study,” says Cooper. The team expects to continually adjust the study and the model based on the findings. Investigators of this study include Savannah Cooper, M.S., CCRP, Hannah M. Worrall, M.P.H., CCRP, Benjamin L. Johnson, MPAS, P.A-C., Charles Wyatt, M.S., CPNP, Philip L. Wilson, M.D., and Henry B. Ellis, M.D. “Evidence-based sports injury prevention efforts must be grounded in studies like these,” says Ellis. “Our sports medicine team is passionate about contributing to the growing data that help to focus efforts and future controlled trials.” Keeping young athletes safe requires a collaborative effort. This is why all of our Centers for Excellence include clinical research professionals like Worrall and Cooper. Learn more about our sports medicine research.
Common Causes of Adolescent Knee Pain

Common Causes of Adolescent Knee Pain

by | Aug 12, 2021 | Research & Innovation

Content included below was presented at the 2021 Pediatric Orthopedic Education Symposium by pediatric orthopedic surgeon Philip L. Wilson, M.D.
 
You can watch the full lecture and download this summary.
 
Diagnosing common causes of adolescent knee pain can be confusing, but it can be simplified by looking at history and physical findings during the exam systematically. To narrow the list of common causes, symptoms are broken down in three ways:

  1. Acute vs. Chronic presentation
  2. Effusion vs. No Effusion
  3. Primarily a Pain Problem vs. Primarily a Motion Abnormality

Below is a list of common knee conditions:

  • Sprain
  • Contusion
  • Stress Fracture
  • Apophysitis
  • Patellofemoral Dislocation
  • ACL Tear
  • Tibial Spine Fracture
  • Meniscal Pathology
  • Osteochondritis Dissecans

Conditions with an Acute Presentation
If the presentation is acute instead of chronic, the number of potential diagnoses becomes much smaller:

  1. Acute vs. Chronic presentation: Acute
    • Sprain
    • Contusion
    • ACL Tear
    • Tibial Spine Fracture
    • Meniscal Pathology

By determining if there is an effusion, or a collection of fluid within the joint, the list of common diagnoses narrows even further:

  1. Acute vs. Chronic presentation: Acute
  2. Effusion vs. No Effusion: No Effusion
    • Sprain
    • Contusion

Then, the likely diagnosis can be determined by looking at where the patient’s pain is located:

  1. Acute vs. Chronic presentation: Acute
  2. Effusion vs. No Effusion: No Effusion
  3. Primarily a Pain Problem vs. Primarily a Motion Abnormality: Primarily a Pain Problem

If the patient has soft tissue swelling and pain around the joint with nothing focal, no bony tenderness and no effusion, it is most likely a sprain.

  • Treatment
    • Protect, Rest, Ice, Compression, Elevation (PRICE)
      • Sometimes an Ace wrap, a splint or a brace is used to immobilize and protect the joint
    • Early protected range of motion
      • Get the patients up and moving early
    • Restore strength

Patients do not need to be referred to Scottish Rite unless their pain lasts for more than three or four weeks.
 
If the patient has an acute problem with an effusion, different common causes of adolescent knee pain from the list are likely:

  1. Acute vs. Chronic presentation: Acute
  2. Effusion vs. No Effusion: Effusion
    • Patellofemoral Dislocation
    • ACL Tear
    • Tibial Spine Fracture
    • Meniscal Pathology

To determine the cause, consider the motion associated with the injury to further narrow down the list of diagnoses:

  1. Acute vs. Chronic presentation: Acute
  2. Effusion vs. No Effusion: Effusion
  3. Pain vs. Motion Abnormality: Motion Abnormality
  • Patellofemoral Dislocation
    • Twist and valgus
    • “Knee dislocated”
  • ACL Tear
    • Twist and valgus
    • “Gave out” / “shifted”
  • Tibial Spine Fracture
    • Hyperflexion
  • Meniscal Pathology
    • Twisting event

Knee Injury and Effusion
How to tell if the patient has an effusion, not soft tissue swelling:

  • X-ray – side view image of the knee
    • Look at the kneecap as it is related to the thigh bone.
    • Look at the muscle coming off the kneecap
    • Look at the space between the kneecap and the femur
      • If there is a curvilinear density that is not the linear muscle, not the deep muscle or the fat pad, it is most likely an effusion.
  • Physical examination
    • Compare the patient’s knees
      • A knee with an effusion will look bulbous and will not have all the concavities around the patella of a normal knee
    • Push on the tissues around the knee
      • If the fluid can be moved from lateral to medial or if you can see a fluid wave, it is most likely an effusion
        • Soft tissue swelling cannot be moved around
X-ray of a knee

Knee Effusion – Patellar Dislocation
When a patient has a patellar dislocation, they relate an instability event where they knee “popped out of place.” There is also an effusion.

  • Diagnosis
    • Apprehension sign
      • While pushing down on the medial kneecap, the patient becomes apprehensive and will sometimes try to stop the exam because they think that their kneecap will become dislocated.
    • “J” sign
      • As the knee is flexed, the kneecap visibly jumps from out of the groove to back into place.
  • Treatment
    • PRICE
    • Physical therapy (PT)
    • Surgery

Refer patients to Scottish Rite for continued effusion or recurrent instability.

Knee Effusion – ACL Tear
When a patient describes twisting their knee and it giving out on them or shifting and they have an effusion, they most likely have an ACL tear. Their knee is unstable. There are four ligaments in the knee: the medial knee ligament and the lateral collateral ligament on each side, with the anterior cruciate ligament (ACL) on the front and the posterior cruciate ligament on the back. When the ACL is torn, the knee has more motion, so patients say that their knee slipped or gave out. The best way to check for a torn ACL is the Lachman test.

  1. The patient lies on their back with their legs out straight and their muscles relaxed, especially their hips and hamstring muscles.
  2. Bend the patient’s knee slowly and gently to about a 20-degree angle. Physicians may also rotate the patient’s leg so their knee points outward.
  3. Stabilize the patient’s thigh with one hand and gently move the tibia forward with the other hand.
    • If there is a great deal of of motion and instability, it is likely because the ACL is torn

Treatment

  • Surgery may be necessary to repair instability or an associated meniscal injury.

Refer any patients with a suspected ACL tear to Scottish Rite.

Knee Effusion – Tibial Spine Fracture
With a tibial spine fracture, the patent usually has a large effusion called a hemarthrosis, or blood in the joint, because of the fracture. These are usually caused by a flexion event like a fall from a bike or skiing or a twist in sport. This fracture will leave a fragment within the “notch” between the thigh bone and the shin bone. This is because instead of the ACL tearing in the middle of the rope, it pulls that piece of bone.
Treatment

  • Surgery
    • Put the piece of bone back in place
  • Casting
    • Moving the leg and putting it in a cast may work if it can be placed in a good position

Refer patients to Scottish Rite for immobilization or surgery.
Knee Effusion – Meniscal Tear

It the patient’s reports a twist or pop event and their effusion appears small while experiencing pain on the side of their joint, it is most likely a meniscal tear. Other things to look for to make the diagnosis are focal joint line pain, a loss of extension, a negative Lachman exam, no patellar apprehension, and nothing positive on their X-rays. An MRI may be needed to confirm the diagnosis. The effusion usually means that there is an internal derangement that needs to be treated with surgery.

Conditions with a Chronic Presentation
If the athlete’s injury is a chronic injury, a different set of diagnoses becomes likely:

  1. Acute vs. Chronic presentation: Chronic
  • Stress Fracture
    • Has been sore for a while
  • Apophysitis
    • Pain at the growth plate
  • Patellofemoral Dislocation
    • Pain around the kneecap
    • Not a specific injury
  • Osteochondritis Dissecans
    • An idiopathic osteonecrosis below the cartilage surface during development

These conditions generally do not have an effusion, and are all activity-related knee diagnoses.

  1. Acute vs. Chronic presentation: Chronic
  2. Effusion vs. No Effusion: No Effusion
  3. Pain vs. Motion Abnormality: Pain

To determine which condition it is, find out where the pain is located.

  • Stress Fracture
    • Focal distal femur or proximal tibia
    • Tender over a small area around a bone
  • Apophysitis
    • Focal distal patella or tibial tubercle
    • Focally tender
  • Patellofemoral Dislocation
    • Poorly localized / Not focally tender
    • “Horseshoe” sign
  • Osteochondritis Dissecans
    • Cannot localize
    • Deep within

Slipped Capital Femoral Epiphysis (SCFE)

ALWAYS CHECK THE HIP IN ADOLESCENTS WITH KNEE COMPLAINTS

When adolescents have activity related knee pain, often with no inciting event, and display symptoms including a limp, walking with their foot externally rotated and a limited range of motion (especially with internal rotation), it may be SCFE. SCFE is checked with a hip rotational exam. If the patient has equal symmetric range of motion, physicians can rule out SCFE and move on to other diagnoses.

Overuse Conditions – Stress Fracture
Stress fractures are an activity-related pain that often happens after periods of inactivity, like summer. They are associated with high activities like running. Patients are focally tender on their bone, but their knee joints are fine. An X-ray usually shows a stress fracture on their distal femur. The treatment for a stress fracture is forced rest until the patient is pain-free and a gradual return to sports.

Overuse Conditions – Apophysitis
Apophysitis is an activity-related condition with pain focal to only one place. The growth plate is going through a transition with a great deal of stress applied in that area with activities. The two main apophysitis to consider are Osgood-Schlatter Disease in which the patient’s pain is on the tibial tubercle, and Sinding-Larsen Johansson (SLJ) Syndrome in which the pain is on the inferior pole of the patella. The treatments for apophysitis are rest, anti-inflamitories, and quad stretching.

Patellofemoral Pain Syndrome
Unlike Osgood-Schlatter Disease and Sinding-Larsen Johansson (SLJ) Syndrome, the patient cannot pinpoint their pain with Patellofemoral pain syndrome. Patients motion all around the knee in what is called the “Horseshoe” sign. They do not have instability in their knee, but they do have pain around their kneecap. The cause of Patellofemoral pain syndrome is unknown, but it is believed to be related to an abnormal balance of the homeostasis of the muscle strength around the front of the knee. During the exam, physicians determine the “Q” angle, or the quadriceps angle. This is the angle between the quadriceps tendon and the patellar tendon. This angle provides useful information regarding the alignment of the knee joint. “Q” angles greater than 14° are vulnerable to patellar conditions. Physicians also look for poorly developed vastus medialis oblique muscle (VMO), a “J” sign, and pain with patellofemoral compression.

Treatment

  • Physical therapy
    • Quadriceps strengthening
    • Knee balance
    • Knee proprioceptive strengthening
  • 70% improved with physical therapy, regardless of associated interventions.

Osteochondritis Dissecans (OCD)
OCD is an idiopathic osteonecrosis below the cartilage surface during development. This can lead to cartilage surface cracks, instability and lesion on the joint. OCD can happen with or without trauma. In an X-ray, a radiolucent lesion is visible.

  • 2:1 Male to female
  • 33% Bilateral

The younger the patient is and the smaller they are, the more likely they are to heal. The location of lesion and the status of articular surface also play a factor in the patient’s healing potential.

Treatment

  • Forced rest
  • Unloader brace
  • Surgery if the patient is older or if the MRI reveals instability.

Meniscal Pathology
A meniscal pathology has a chronic presentation with no effusion, but a motion abnormality instead of pain.

  1. Acute vs. Chronic presentation: Chronic
  2. Effusion vs. No Effusion: No Effusion
  3. Pain vs. Motion Abnormality: Motion Abnormality

The patient says that their knee pops or snaps. They may also have a loss of extension and a limp. These are signs of a discoid meniscus.

Discoid Meniscus

  • Discoid meniscus is a congenital malformation of the meniscus
    • Affects approximately 1:100 children
  • Mechanical symptoms in childhood with no trauma history
    • Snapping in the knee usually occurs between the ages of 2 to 6.
  • Palpable / audible “snap” at lateral joint line during exam
  • Visible bulge at lateral joint line

As children get older, the discoid meniscus presents like a regular meniscal tear. The treatment for this condition is arthroscopic surgery if the patient is symptomatic.

Refer patients to Scottish Rite for mechanical symptoms or loss of motion.