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PIGEON TOES, KNOCK KNEES,AND FLAT FEET:WHEN TO SEE THE ORTHOPAEDIC SURGEONI.M. Doctor, M.D.
My OfficeMy City, State
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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.
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What is an orthopaedic surgeon?
MD who specializes in treatment and health maintenance of musculoskeletal system (bones, joints, ligaments, muscles, tendons, cartilage and spine)
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What is an orthopaedic surgeon?
The expert in treating the musculoskeletal system
The expert in maintaining musculoskeletal health
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Educating an Orthopaedic Surgeon
College Medical School Internship Orthopaedic
Residency Fellowship (optional) 2 Years Practice
TOTAL
4414(1)2
16 years!16 years!
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What do orthopaedic surgeons do?
Diagnose Treat
Medication Physical Therapy Exercise Brace Surgery
Prevent
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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
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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
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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
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Pigeon Toes, Knock Knees,and Flat Feet
Feet turn out/in
Knock knees
Bow legs
Flat feet
Common conditions that are often normal:
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What is normal? What is abnormal?
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History
What is the specific concern? When does it manifest? Duration? Improving or worsening? Patient’s medical history and family
medical history
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Who is concerned?
Parents Grandparents Pediatrician Teachers Others
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In-toeing and Out-toeing
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In-toeing
Common in babies and toddlers
Almost always resolves without treatment
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In-toeing
Not painful in and of itself Not associated with early arthritis Can rarely be associated with knee
pain and problems
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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)
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In-toeing: Metatarsus Adductus
Majority are flexible
Resolves by 3-4 years of age
10% stiff and may benefit from casting
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In-toeing: Tibial torsion
Common in infants Usually resolves itself May be treated with
surgery in more serious cases
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In-toeing: Femoral antetorsion
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In-toeing: Treatment
No treatment necessary in most cases
Ongoing observation may be recommended
Surgery in some severe cases
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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
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Out-toeing
Usually in normal range Usually causes no problems Rarely requires special care
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Angular Problems
Knock-knees (genu valgum) Bow legs (genu varum)
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Angular Problems
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Angular Problems
Physiologic Pathologic
Trauma or injury Rickets Tibia vara (Blount’s disease) Skeletal dysplasia
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Angular Problems
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Age 2 Age 4
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2 2+
4
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Flatfoot
All infants have itMost children have itMore than 15% of adults have it
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Flexible flatfoot
Often resolves with growth Not correlated with disability in military
populations Not affected by special shoes, inserts, or
braces
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Stiff flatfoot on the right – does not correct on toe standing
Stiff flatfoot
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More foot pathologies to consider
Clubfoot Calcaneovalgus
foot
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Clubfoot
Incidence 1:1000 Boys > girls One or both feet
turned inward May sometimes be genetic
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Clubfoot treatment
Serial manipulationsand casting
Begin first week of life, if possible
Perform weekly 90% of routine clubfoot respond
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Calcaneovalgus foot
Most common foot deformity at birth
Foot points up Resolves
spontaneously Associated with hip
dysplasia
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When do you need to see a pediatric orthopaedic surgeon?
Over three years of age with documented progression of deformity
Stiff metatarsus adductus
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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
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American Academy of Orthopaedic Surgeons6300 North River Road
Rosemont, IL 60018
www.aaos.orgwww.Orthoinfo.org
Resources
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What are your questions and concerns?
Pigeon Toes, Knock Knees, and Flat Feet
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Thank you for participating today Remember, your orthopaedic surgeon can help get you
back in the game
Pigeon Toes, Knock Knees, and Flat Feet