Chapters Transcript Video Things That Go Bump in the Day Thank you. Um In a non sycophantic millennial way, it's uh it's always an honor as a surgeon to be invited uh to come speak to this group. So uh with much gratitude, uh much kindness and appreciation. Um This is fun. This is a cool meeting. Um And this is very, very, very low key. So, you know, I put, I put these talks together and you do the title and you have your thing and your academic appointment, your professional appointment. But like, what are you thinking? And what am I really thinking? You're like some kid with an annoying Ortho problem. How do I manage this? How do I get him in the office? And what do I think about myself? I am the writer of the emails, the owner of no authority. I have no carrots. I have no sticks. I have no nothing to motivate people servant to divisional operations. For sure, non remunerated correspondence and uh continuous failure of personnel management certainly continues to be challenging. So um this is gonna be fun. Um Jim Beatty, my mentor said no one will ever remember you if you go along. So I promise we'll get us back on schedule. This would be a bit shorter than an hour. Uh I do have some active disclosures with the Pizzo company. Nothing relevant to this talk for sure. Uh And I'm very grateful to participate in several of our professional and academic societies. So, um or team, there's uh Doctor and Doctor Van. No, and myself, uh we're holding down the fort. We've uh hired a couple of A P P S to help with access for our providers. We are all over the uh low country here in North Charleston, Mount Pleasant West as, as well as Neon. And then we're really happy we go down to um uh ok, once a month or so. Uh And so for our low low country colleagues, we're able to offer some access down there and uh personally, it certainly has become a bit of uh um Cahill's chicken market is pretty awesome down there. So between that and the Zach, it's a lot of fun. It's a fun field trip every, every, every month for myself. So, um this is just like Joe Ortho stuff. This is just stuff you're gonna see stuff you're gonna see in the office. It's your average morning or afternoon appointment. And this is meant to be like really, really, really low key, you know, some videos, some pictures, honestly, there's gonna be a fair amount of philosophy, a little bit sort of how I treat these patients, um how to provide some counsel how to write, how to provide some reassurance. Uh, and then we'll talk about the things that go bump in the night. Right. The stuff I probably shouldn't miss that or here's the back of the neck or was probably needs to go see the Ortho crew and that type of thing. So I promise this is not a bunch of like exotic, weird orthopedic surgical stuff. There are very, very few x-rays, I promise you in my heart, I think I did not put any pictures of surgery in there. Um And it's challenging when you talk about an orthopedist in medical literature and you know, air quote science, but there is some data here and we'll support it with a few references and how, excuse me, happy to provide those as well. But um this is meant to be very fun, sort of Lionel Richie, easy, easy like Sunday morning type of thing. So um so Jack Flynn is a house of Philadelphia. Jack tells me that there is a special place in purgatory reserve for human beings that read slides to literate audiences. So I will read a few things, but most of it is for the intonation, right? For the for you. Like, can you take a look at my seven year old quick? You know, she's uh we're pretty sure she's always toe walked, we're starting third grade, you know, toe walked as a toddler. It was cute. We had the cute shoes and all that type of stuff. And then kindergarten happened in 1st and 2nd grade sports are starting and like, I don't know, I, I, I thought she would kind of come down over time. I thought this would get better after starting school. So, um, what do we do or is this bad or, you know, where do we go from here? So, so here she is here, she is in the office based setting and, and you know, this is just a great opportunity to kind of just talk about the gate cycle in Children, right? So we look at this girl and we kind of go again, we talk about the gate cycle. We sort of start from the top and go to the bottom. You know, head is level, shoulders are level, pelvis appears to be level. So she probably doesn't have a leg length discrepancy. You know, we can look at like the hem of her t-shirt line, right? That doesn't appear to be oblique or uneven either. So looks like she's got a level pelvis looks like she's got a reasonable hip range. Emotion, looks like she's got a reasonable knee range emotion as well. You know, we look at her feet and we can see that she is toe walking right. So rather than having that, you know, the three rockers, right, the hind foot, the mid foot and the four foots, right, she's just a toe toe gates, right? But her gate appears to be pretty coordinated. Right. She doesn't appear to have a limp, doesn't appear to have any Antalgia. Doesn't appear to have any asymmetry if you will. I think that thing with the left hand is her being silly, right? You know, we've talked in the past before about asymmetry network extremities is maybe a hemiplegia type of thing. But this is just a silly little girl being silly, you know. But, so she's got this toe toe reciprocating coordinated, non intelligent git. So, ok. Cool. All right. So let's do our static exam. Let's check it out. So, nothing too scary, right? So, you know, again, in ments, the skin, there doesn't appear to be any call, there's no ulcer, there's no skin breakdown. Sometimes you see those kids who with toe walkers and they'll see like pitting of the nails, right? They're really flexing their toes. She doesn't have any nail deformity. There's nothing really else going on about the, the skin system, the extremity, you know, and so when we talk about anatomy lesson and what's the reasoning behind this? Right? The triceps, the surrey, the three muscles, there's the two heads of the gastro and then there's the soli and those three kind of coalesce and form the achilles tendon. And the difference is, you know, is this a gastro issue or is this an achilles issue? And so the gastro crosses the knee joint and so that allows us to tease out whether or not it's a flexible thing from a gastro tightness versus potentially a rigid thing from both the gastro and the solu is being tight even though the knee is flexed. And so that silver skull test that Scandinavian buddy a million years ago, right. We do the knee extended and then the knee flex position and we can annotate this and it helps us kind of understand it a little bit better. So we see right image on the left she's got, you know, equinus, right, maybe 2030 40 degrees or so. So her knee is ex extended, the gas trucks under tension, we try to push the ankle up, it's not going anywhere. But when we flex her knee and take the gas truck out of the equation, she's got pretty good door of flexion, right? She comes to at least neutral. So, so that's reassuring. So maybe this is just a muscular tightness issue, maybe this is not a true tendon contraction. So that's our silver skull test. That's kind of how we assess the flexibility quo of some of these kids who are tow walkers. And that also allows us to provide some of that context and reassurance to the family. Should we start? We'll talk about the treatment ladder start with P T or maybe does this need to kind of escalate to an orthopedic size, you know, sooner rather than later? So the differential diagnosis is enormous, right? The differential diagnosis is absolutely remarkable, but for most families and most Children this idea, idiopathic, habitual. I try and shy away from the term behavioral. Yeah, I married a clinical psychologist so I'm fairly sensitive about some of the stigma that comes with that. Um, and so using words like postal habitual idiopathic to, to help families contextualize this but really kids around age five or so, I mean, 2 to 5% will be toe walkers. Right? And you'll see them in the playground, you see it in kindergarten, you'll just sort of see that out and about. So that gives the family a little bit of context that, you know, quote unquote, we're not alone, you know, and that this is something that a reasonable number of people in our community will see. But then the slide of the, I mean, the the bullet point at the bottom I think is probably the most important one is to give families that reassurance that there's pretty good data. You know, even in Joe Ortho world, there's pretty good data that the vast majority of idiopathic toe walkers will resolve by age 10. So to provide them some of that context, then to say, OK, this will probably go away on its own. But how aggressive do you wanna be treating it? And so, you know, the the long term data that we counsel families, you know, that stretching can improve the ankle range of motion. And we'll talk, we'll talk about P T and physical therapy in a little bit. There is data that says that yes, if you're a persistent toe walker, you can develop ness over time. But truly, this bottom point is probably something that I tell every single family in every single toe walking clinical encounter. There is no data. There is no, no, no, no, no data that says that being a toe walker or having persistent toe walking will leave to lead to any adults, podiatric orthopedic, foot and ankle, lower extremity issues. So that, that really provides us that reassurance that there's really nothing out there. So it's ok to be a toe walker, it's ok for your child to walk on their toes. They're not harming anything, they're not hurting anything, you know, the they're not chewing their ankle up, they're not causing some sort of tendon problem, these type of contextual things. So, so this is really, you know, in most of these four cases, it's really, it's really like a ladder. You know, we start at the bottom, we climbed to the top, you know, and the first step is that observation, reassurance again, going back to that 80% resolve by age 10 or there's no data that this will get any worse over time that reassures the families that this is ok. And if the point of the, the point of today's appointment is cool, my kids not ruin anything. Wonderful. I'm happy to see you. We can come back in three months we come back in six months, you can have a good life, call me if you need me type of thing. But to provide that family that at least that confidence that, ok, they've checked that box, there's no skin issues, there's no neurologic issues, anything like that. The vast majority of patients will start with and successfully treated with the P T or physical therapy program. And usually we'll start with a supervised program and then a transition to home exercise program kind of depends a little bit on the age of the child and kind of depends on the motivation of the family. I offer everybody kind of the, the, the book, right? So twice a week for six weeks and the joke I tell people is as much as your gas money and copay wants to do this, you're totally fine with me if you and your therapist have a great relationship and this is perfect, you know, go go as much as you want to type of thing once the child gets a little bit older and they've gone to 234 sessions. They're like, I think we got the hang of this. We got our thera bands, we're doing our exercises when we brush our teeth. It's kind of a nightly thing. We've kind of made this contextualized into our life then transition to home exercise program. I think that's perfectly fine. You know. So again, it's as aggressive as the families wanna be. So we start with reassurance. Next step is P T physical therapy. You want to come back in six weeks, come back in three months. Let's kind of see how you're getting along again because there's no data, you let the family drive. So if they're unhappy, if they are unhappy with the toe walking, if it's a discordance in the playground type of thing, you know, or if it's, uh, I don't like how my child looks or my child doesn't like how they look or they don't like being a tow walker. We let them kind of escalate themselves up in the ladder because the next step is something like night splints, right? Those sort of dynamic two popsicle sticks and rubber band type of thing. Night splints. The idea here is while the brain is asleep that dors selection moment arm comes on the foot and ankle is meant to stretch out the gas truck on the achilles. They can be expensive and they can sometimes not be covered by insurance programs. So, just a little pause with families. Uh, the next step on the ladder is to employ like a P T for a serial casting program. There are some orthopedists that do. Uh, but we are very fortunate. We have a couple of local P T in our Charleston area who are really into a serial casting program. And the idea here is to slowly stretch that foot and ankle out over time with a series of manipulative casts. Botox injections historically, were offered for many Children who are toe walkers. Um But this is, you know, it's like a unicorn in orthopedics, right? This is a level one study. It's like a true unicorn kind of floated across the rainbow. So Mountain Scandinavia published this almost 10 years ago. Now, there's really no difference between Botox injections and just a stretching program versus, you know, combining the two. So, uh referral to psychiatrist potentially for Botox, but you know, surgery is really reserved for families that want surgery. There's good data here. So Mulkins published a couple of studies here in the or the world and the gate world that improvement in range of motion improvement in gate portfolio, improvement in quality of life. So for the family that's ready for an operation, we're more than happy to offer that to them, there's good data to support that. Yes, it will help. Uh But again, we let them come to that. So again, there's less data here and now it's a little bit more about philosophy. Again, going back to that 80% resolve by 10 and there's no data that says there's long term problems. I let them be in terms of how mo motivated they wanna be for this thing. So if it's see you later, see you later and in my hands, kids who get toe walking surgery, you know, achilles lengthening or fractional lengthening or tendon things or muscle things they're, they're the ones who really come in asking for it. They either have persistent pain, they have issues with shoe wear. Again, we can say the word bullying out loud, the, the term I tell families is kind of discordance with your peers or how the playground looks or if there's just dissatisfaction with sports or how things look. So, um, again, based on the data that it will get better or, um, by age 10, I really try to avoid surgery in younger kids. Maybe even more so because of the ownership type of thing. Right. So, a kid who's, is the owner of an eight year old in ownership. I certainly know she started, she's gotten to the age now where it's just like the mini corrections. Right? For those of you who have like juveniles and older kids, it's that I'm here. Right. Just many, many corrections from your Children. It's beautiful. Mhm. Right. Ok. Ok. Got it. You know, but that ownership type of thing, right. A kid who is 10, 11, 12 is gonna be able to comply a lot more with non weight bearing or be able to comply with P T or that type of stuff. So, again, engaging the child is an active part of the conversation is important. So, um, the red flags are the red flags, you know, historically tethered cord, the child that was a normal heel toe walker at 123 and then all of a sudden kind of came up on their toes at age four. That's a classic presentation for a tethered cord. Again, neurologic things, spasticity, asymmetry, reflex issues, bowel and bladder type of stuff. These are, these are obviously things that go bump in the night rigidity, no flexibility at all. We talked a little bit earlier about like nail pitting. You know, as a kid gets to be 10, 11, 12, they've been a persistent toe walker. They start having nail discordant, they're kind of hyper flexing their toes as well. Again, these are the type of things where yes, we're more than happy to open up that conversation with the family, you know, is an operation or surgery, the right thing for your child for their quality of life. Just a brief note on uh you know, our friends in the spectrum that there's good data that sensory processing is associated with our friends in the spectrum. There's not a lot of data that says that because you have autism or a spectrum disorder that you're gonna be a toe walker. Again, I think that kind of comes up as a thing frequently, but I would tell you anecdotally and again, without any data that really we see more Children without autism spectrum who are toe walkers than with if you will. But the treatment ladder is essentially the same. You just need to be a little more sensitive about some of those sensory processing things right? Night splints serial casting that type of stuff. Just eyes wide open with families about where that child falls in the spectrum and where their sensory stuff is. So OK. Next case, four month old. Cool. My baby has this like really weird clicking noise in her hip. Only when I, you know, only when I change the diaper. Do you think it could be the overpriced European imported all natural woven carrier I bought since I was guilted into it by my neighbors in the Instagram feed as you're swinging around. Right. Looking at the charts. So the family cannot see this like full level eye roll. Right. Right. We laugh because it's true. Right. We laugh because it's true. So OK. But like, so, so hip click type of thing, you swing around, you take a look at the chart, you baby's got this weird hip clicky thing. I'm changing the diaper kind of when I, you know, sucker up on my hip when I'm at Costco, you know, all that type of stuff. So there's, there's nothing really on the chart though. It's not scary. You know, family history, your mom's got no history, sort of. They said she was breached in the carry flipped, Born vertex and your exams were all pretty rock solid. You know, you've known them, you've known the family, you've known the kid and exams seemed to be ok. You don't really worry the past. But all right, it looks like we got a little yellow flag coming up here. Mom's worried. Let's kind of take a peek if you will. And so what does your exam look like today? Right. So, your exams pretty dang reassuring. Right. So you got the baby up there, maybe, most importantly, I've got wide symmetric abduction, right? So symmetric abduction, wide and full, there's no skin fold stuff you don't see any fat depositions the way the lower extremities are kind of laying looks OK? And, and then the stuff that, you know, right. So there's no clunk, there's no sort of true instability if you will, there's no Barlow, there's no, it's pretty smooth. I don't know, like maybe, maybe you feel this like mechanical phenomenon, right? When you're kind of coming from the abducted and flex position kind of extended. And so like here's your exam here. And so, so for me, you know, a little sort of infant baby hip exam, pearls, the, the your, your hands really should be on like the proximal portion of the hip or the greater trochanter, you know, the analogy if you will sort of like the, you know, like a pistol or a gun if you will. So your hand is on uh on the, on the tibia and then your finger is really feeling and there on the greater trochanter, you know, and again, if this is a, I think the best sensitivity is a one side at a time type of thing rather than kind of roll, roll, flip, roll, flip, you know, really kind of dial in, feel the right side first, roll it back and forth, roll it back and forth, feel the left side next and then you can kind of do both sides, right. So we see on this baby's exam here, you know, left side, right side. I don't know. Do I feel something kind of flexed, abducted extended? Do I feel something maybe? Question mark. Right. Tell the mom. Oh, yeah, totally. I feel, I feel what you're feeling. Totally. Right. Provide that context and reassurance, you know, you got your lips out. You're like, right. Totally. Right. You're not crazy. You're not crazy but, but I don't know, but maybe right, we felt, we felt lots of like hips and clicks and clicky things and that type of thing. So, you know, is this uh you know, where do we, where do we go? Our family practice friends have this amazing diagram kind of allows us to, to, to dial down, you know, where do we go and where do we need to get scared? You know. And so if we kind of look at our little lightning bolts, if you will, I guess there is a risk assessment, right? His breach and, and we examine them, but the exams pretty normal, but there is a risk factor. I don't know, maybe we should consider an ultrasound, you know, and just, just take a peek here and we look at the right side, you know, even when there's not any risk factors and there are findings on your physical examination. Again, ultrasound or referrals is really all over this chart, you know, and, and there's a difference between an instability, a bar or, and a click. But I, I, I think irrespective, I mean, again, all over this chart and all over A A P as well as, you know, it's OK to have a low threshold for referral type of thing. I'm gonna talk about this at the end, sort of, this is a good place to interject this. You know, you look at the program committee and like the stuff that our front line providers are being asked, the diversity of things. And again, I'm not, this is not brown nosing, but like, it's remarkable, you know, this is all that I do all day long. And so I, I sort of hat tipped off in terms of the variety of the things that you see. So if there's any concern, I think for a radiation free ultrasound and then, and then a referral, I think there's really, there's really no harm, you know, and the joke that I tell families is, you know, long gone as a surgeon, you know, on the phone, you know, why is this in my office? This doesn't need to like that's, that's over, you know, we don't really do that anymore. So if you're worried enough and the family is worried enough. Just send it right. It's an ultrasound appointment. It's easy type of thing. So that's, you know, that's just a kind like, yes, it's ok and please send it along. So anyway, ultrasound is all over here and so the kid, it kind of has a risk factor exams. Ok. Like, should we get an ultrasound? Like the data tells us, we probably should, you know, we probably should. So these are really large series from our side of the pond and the other side of the pond. I mean, this is a giant series of like 1800 people. But these are all kids with like clicky hip referrals, right? So no risk factors and a completely normal exam. Barlow is normal or is normal, no leg discrepancy, no skin issues. But I mean, in some of these series, like 25 to 30% with something on the ultrasound, whether that's mild dysplasia, maybe even a true dislocation, you know, and 15% of these referrals will get some sort of intervention whether that's a short course of a harness and abduction brace, even some kids will get an operation if they fail the harnessing program. I mean, truly, truly, you know, the data would support if there's something weird on a hip exam, even if it's a mechanical phenomenon with wide abduction, just scan it and it's done. And we're fortunate, I mean, our ability to get same day ultrasounds here and even if you don't live in as, as served the community. If you're somewhere that is, does, doesn't have that access even if you want to get an ultrasound from an adult provider. You know, we see a lot of uh friends from Buford who get an ultrasound from their team there or Myrtle Beach or that type of stuff. That's ok. You can bring it and if the ultrasound doesn't look satis, we can get a second one here. It's easy for a same day add on for us. So um better to not miss an image uh especially with the radiation free. So uh the data would support. Yeah, for a clicky hip probably. And so like what is this though? Like what is this stupid thing that I'm feeling? What is the mom feeling? What is happening when I'm coming from that hip flex that hip extended position? And you know, the best that we can kind of surmise in our world is probably the est tendon, right? So the inmate bone or the pelvis is basically this giant nugget of cartilage, right? And it turns into bone over time. And so the undulations over top of the pelvic brim. So that's kind of where that yellow arrow is standing right there. The pelvic brim. So the so muscle and tendon, the large hip flexor starts the lower part of the spine courses over top of the pelvic brim and then starts on that little lesser canter there. I drew that red line. I was really proud of myself, by the way, it's not too squiggly, you know, I'm a grown boy. I can draw. Right. Uh But that's the idea here is as you're in the flex to extended position, you're gonna put the hip flexor in attention. It's gonna roll over the pelvic brim. And that, that's kind of what you're feeling when that's happening. And that's, that's at least the most likely ideology for a for a clicky hip then in the setting of a normal ultrasound. So image away the stuff you don't wanna miss is this stuff is the stuff, you know, right. The stuff that you don't wanna miss is the stuff that, you know, things like true leg length discrepancies. So we can see the seven month old girl here. You can kind of see that little indentation where the patella meets the proximal tibia. We can see her pelvis is fairly level and we can see the left side is proximal, the right side is distal with uh with evidence of a leg leg discrepancy, you know, with the left hip dislocation maybe more importantly, you know, is, is being thoughtful for that abduction portfolio. And that's what I talked about during the video, you know, do one side at a time, do your left side, your right side, then do both, you know, let the kids chill out a little bit left side, right side, then both and we can see that this baby has a discordance in their abduction. So the right side has pretty wide abduction, 75, 80° or so. But this left side only has about 45°, 45° of abduction, which signified again, a left hip dislocation. So those types of things are important, you know, thoughtful, critical physical exams, you know, at each time during the infant's presentation. Ok. This one's great. This one is awesome. All right. I'm worried. My daughter's been having back pain. She does gymnastics. Right. She's really good too. She's like, she's pretty good. She's really good. She's been doing gymnastics her whole life. Level eight, level nine. We got, we got a zipped up kit. We're doing great. The, she didn't have like, an injury or anything particular kind of a weird fall over the summer, but now it's December, you know? Ok. And so what's going on? Well, we're still practicing 40 hours a week. Ok. Great. How old is your child? 13? Uh-huh. Great. Who drives her there? Uh-huh. You. Right. Right. So, it's beautiful. It's perfect. So, but, but, but, but we see, well, you see this all the time, right? You see this all the time. So persistent, low back gymnastics. It's not really slowing them down that much, but it's slowing them down enough that they at least want to come sort of get checked out. And like this is totally the look on your face. 40 hours a week. You're driving them there, so. All right, so you see her. Alright, so let's check her out, right? So um this is another video of an of a of a kid that I know two but you know, again just this is your this is the kind of plug here for me, you know, for most musculoskeletal things you wanna do an exam with an appropriately um exposed patient if you will, you know. So um trying to listen with the stethoscope through a sweater is pretty challenging, you know, trying to do a exam through their sort of jacket over the summer is probably challenging. So get out the stupid blue shorts, you know, get out the gowns, get out the stuff and take a peek if you will. So let's see here this one. Ok. But again, we want to see what their motion portfolio looks like. We wanna see them inflection, we wanna see them in extension. The, you know, the majority of patients who are gonna present to you with a back pain complaint will more likely than not have limitations in their extension portfolio. I'm sorry to put this one on repeat. This kid also jacked out of his mind, you know, so here he is inflection, but it's interesting look at what he does at the lumbar spine. He's not really extending at the lumbo saco junction is he he's really more extending, you know, sort of through his lumbar junction. So because he is flexed as he comes back into extension, he does, he sort of arcs above his low back if you will. It's interesting, right? So you want to take a look at their motion portfolio first kind of see what they're doing? Ok. And so this is, you know, Murphy's kind of quick and dirty 32nd neurologic examination. It's easy to rule out tons of scary stuff with a super easy, quick and dirty neurologic examination. And again, most of the stuff that we're gonna pick up, you know, as a first time appointment, front line provider is either gonna be a motor issue or a reflex issue. Again. So sensory discordance, asymmetry and sensory and sensory anomalies are exceptionally rare, but it's kind of motor sensory reflexes. You know, our motor OMs, we're gonna go through some, the video S one gas rock five is E H L. That's great to extension L four T L interior ankle door selection. L three is a quad at knee extension, L two is the abductors and L ones. So sensory dermatomes, middle, the knee, middle, the ankle, foot, out of the ankle, middle, the knee, middle, ankle, foot, out of the ankle. Easy to pick up. Most of your pathology is gonna be at L three or below for most of these kids who come in with some sort of low back issue. Although as we'll talk in a minute, most of it's not gonna be any pathology at all. Uh, and then 10 Nintendo reten achilles reflexes, long track signs, Clonus Bobinski, those types of things. And that's honestly where we pick up most of our, um, you know, neurologic anomalies if you, at least in our, in our orthopedic spine clinics, uh, kids with asymmetry or, or hyperlexia hypo reflexa. All right. So, here's the quick and dirty. Push down the gas pedal. That's gastrocnemius. S one, right. Show me a thumbs up with your big toes. That's L five. That's E H L ankles go up. Hold it till San L four, hold it. Ti be Santi L four. Knee kicks out L three, quad, knee kicks out L three quad near the sky near the sky. Open, close, relax and go loose but tell her tendon, tell her tendon 10 achilles, 10 achilles and then brief check, clonus and then long check signs. We'll do it one more time here. She's like a senior at Clemson. Now, I feel old. It's gas. Rocket S one. Gastro X one great toes go up. Show me a thumbs up with your big toes. That's E H L tib. Ant is L four, right? We're gonna kick out for L three for our quads. We're gonna kick out for L three for our quads. L two is gonna be our abductors. That L one is your, you get your abductors L two and, and then immediately with your abductors as well and then your reflexes. And I think my favorite child is when you get done with your neurologic examination and then I'm looking up at the kid and the kids still holding two thumbs up. Right? That's my like that's my favorite kid. You look at the kid, the kid still holding two thumbs up, show me a thumbs up with the big dos and they're still doing this. Like I got it type of thing. Following instructions is remarkable, right? Ok. So like this is rampant, right? So this this will see you, you will see this, this will see you, you will see this and and the data is out there, right? So back pain is an exceptionally common complaint to both specialists as well as our front line providers if you will. So 36% of patients will have pain at some point in the past year, 14% of patients will have like an over two year history of back pain. And then if we look at like large large large cohorts of adolescent athletes, you know, up to 85% will have some sort of, you know, instance of back pain at some point during their athletic career. So we see this, this sees us, is it bad? Is it scary? What can it be because the differential is enormous, right? There's all the cool Ortho over there with the small bullet points, right? The I can't wait to do some cool operation and Joe Ortho type of thing. But what like, what is, this is muscular back pain, right? This is some sort of muscular back pain that doesn't have a type of either, you know, physical exam or imaging identified pathology. And so, you know, how do we navigate the waters with these families and how do we navigate the waters? Um, you know, with imaging therapy referrals, who goes where, what goes, where, what do we do type of thing? All right. Cool. All right. So I saw skin looked OK. No weird stuff. No dysraphism, no hairy patches, no dimples, a reasonable motion portfolio, maybe a little limitation, extension, neural exam looked pretty good though, right? So no weird stuff there. OK. So like, so where do we go now? What do I tell the family? You know, image first or P T when you look at most like professional society recommendations, you should be more likely than not, not imaging, right? Most of those recommendations are gonna be conservative management. Anti inflammatory P T. Philosophically, I think it depends a little bit on the family. I don't think, I don't think there's a harm for a low dose X ray, just an A P and lateral lumbar spine, you know, and you, you know the on your families, right? You know who's gonna be different between like cool toe walking? See you later versus our second case up a baby with all the baby bjorn type of thing, all that type of stuff. So, you know, you know how to manage and triage your families if you will. And so I, I think it's OK. The, the amount of radiation that we are now admitting from a traditional E P lateral lumbar spine is so much lower than it was 20, 30 years ago. I really don't think there's that much harm for a quick film even for that family. For peace of mind to say, OK, it's not anything on the x-ray. I'm cool with that. Now, what do you have to say? Where do I go from the treatment treatment algorithm? But I think, I think the corollary is appropriate, right? Because really irrespective of almost any diagnosis besides some, again, Joe Ortho whack a doodle type of thing once in a million P T is gonna be your first line treatment. So I, I think, you know, counseling the family and talking to them um about where they want to go and what they wanna do is appropriate. Um I, I'll give a couple of sort of, you know, philosophic considerations with P T. I mean, I would I send a lot of kids to P T for lots of reasons. Again, similar to the toe walking, you know, platform. This is you offer them the full script and, and maybe for some of these gymnastics kids, it's probably better for them to prove to you or our cheerleaders or our tumblers or football boys or that type of stuff or, you know, our field hockey gals, you know, to offer them. And I need you to commit to this. Right, twice a week for six weeks. I got the thing at the bottom there, you know, would see lots of 2nd and 3rd opinions and they're coming in. I want the surgery. Ok. I just want it. Mom, I want the surgery. I'm well, like I, yeah, I need you to see me through this. Right. You have to commit to me that you're willing to at least put something into it. So, you know, again, starting with a supervised program and then transition to a home exercise program and then maybe more importantly, a therapist they like and a therapist that works well with them, right? They don't, they don't need the, the thing, you know, that the nursing home folks are getting with the exercise bicycle. You know, you need to make sure that they find like a therapist. They like it. And literally like this is exactly what I tell people. I want you to find a therapist. I'm gonna give you a prescription call a few places. Google. I'm happy to give you a list of places to find something that's close to your home, find something that works well with your insurance program and then find a young dynamic sports p T someone you like someone you jive with, right? We don't want your daughter to go to, you know, Betty Jo and the golden girls, grandma. Total hip program. We want someone to be mean to your kid on purpose, right? That type of thing because you want them to be motivated to. Again, most likely the pathology is gonna be normal. So young, dynamic sports P T so a a little philosophy but I think goes a long way for families to kind of get that context if we are gonna image them again, all we need is just an a lot of the lumbar spine. That's, that's truly all that we know. We see this kid got a little scoliosis. I got lazy and just pulled us from a different talk. But again, a P lateral, the lumbar spine should be able to rule out the vast majority of any pathology because the next slide is probably far, far, far more important classically, right? We said, oh, you need the four views, the lumbar spine A P lateral and both obliques, right? Those those eponym, the Scotty dog stuff. And we're looking for the lysis. The issue is is that the amount of radiation that's needed to obtain these oblique views is significantly more than just a classic A P and lateral. And Jen Beck uh out in California who's awesome, wrote a really nice paper that said that the diagnostic yield from getting A four of you is really, really, really not all that much higher. So like save the kids, save yourself the heartache and A P and lateral lumbar spine is literally all that you need to get whether you're gonna image them first or send them to P T first and image them second, just a P lateral lumbar spine. Um And then we're happy to take a look at it. Should that need to be the case? OK. So, so what's my ladder like, where do we go? That type of thing, you know, observation activity modifications. I mean, bullet point number three is pretty real, you know, the joke family is I had a gymnast take a swing at me when I tried to pull her out of the gym. But I let the kids make their own decisions. I mean, gymnastics and cheer and those types of things. There's plenty of other things they can work on that are not back, walk overs and dismounts, they can do pull ups and they can do flutter kicks and conditioning and all that type of stuff. So again, because the majority of this is gonna be a muscular type back pain. The reassurance here is your child's not harming themselves, you know, so they can kind of participate to the fullness of their ability, you know, as long as their symptoms and confidence allow. But we start with that, we start with activity modifications and kind of let them auto rate. Uh I don't write letters to gym coaches. I've been asked, what, what's my, what, what can I do? Like I don't write programming, but I'd say you can do what you wanna do. So we start with P T again, ask them if they like their P T, if it motivates them, then you can sometimes ask them to move on to another P T. You know, again, I'm not a priest, I'm not a psychologist. I married one uh but kind of dialing in with that sometimes I think is helpful for families if they like who they work with. So advanced imaging. Right? So where do we go with advanced imaging? We've had a plane x-ray, we've started with P T for the vast majority of kids. I think you're probably ready for an MRI. Once they've done that course of therapy, they've proven to you twice a week for six weeks or twice a week for three months, they've really done it. Um I didn't put in the, in the slides here, you know, anti inflammatory usage. I defer to families to whether that's an over the counter emotion or leave, you know, a 7.5 or 15 meloxicam is kind of my go to for a short course if they need it just to kind of get over the hump if you will. But, but you know, we're looking for that other pathology. We're looking for facet disease, we're looking for this disease, neural encroachment. Again, the Joe or stuff we get excited about. So, you know, MRI can be valuable and again, normal mirrors, it does add value, you know, we've had persistent low back pain. We've done therapy, we've had a plane X ray which is normal. There can be some value, at least adding diagnostic value that may not be surgical value, that may not be intervention value. But again, you guys know too, families feel so much better. At least knowing they have a name on something and I have, I have this and it's on the report and now I can, now I can go to Google and look it up to high heaven. But like now at least I can put my hands on something and I feel like I can own it. So there is some value there. And and again, I also, you know, council families, you know, most insurance carriers are going to want to ask you to prove to them that you've tried that stuff, right? So six weeks of therapy, conservative modalities, the these are the types of things that we document in our notes too to kind of help get MRI S approved. But MRI, no sedation, no contrast lumbar spine um helps in terms of, you know, diagnostic yield and a certain percentages. So like where do we go here, Joe Bro? Right. So at this point now you've been following a child for three months, they've had a plane X ray. You may or may not have got an MRI no matter what it shows in the vast majority of cases, they usually come see us at this point whether that's just for specialist expertise, reassurance, where do we go from here or if there's an abnormal finding on their MRI, you know, do we need to take a left off the freeway and talk about scary words that, you know, start with s and, and with most kids that you see, you will not prescribe a brace for, you know, rigid L S O is kind of on the lysis ladder, um, and operating. But I made a promise, I made a commitment to you guys that I wouldn't show any pictures of surgery C T scan. Really, really, really is only because the magnitude radiation is really reserved in my hands, only for surgical planning purposes. Truly, truly. So we really don't get C T S all that frequently in most kids who have back pain. And then I would say I have almost never ordered a bone scan. I can, there are about two cases I can think of where I ordered a bone scan, where it was the family that had done therapy and done. They had even wanted to do a brace. They had an M Ria C T scan a case and, and they just kind of kept coming back and you say, are you willing to take this on, you know, in the magnitude of radiation for what will likely be a low diagnostic yield? They kind of needed it for their closure. But truly, there's really almost no indication for George Bush, nuclear, nuclear medicine. That's right. Nuclear nuclear medicine. Getting old nuclear medicine in 2022. So nine times the radiation with very low additional diagnostic yield. So plane X rays and MRI are really going to be the mainstay in the go to course for the vast majority of these kids. The stuff to be scared about is the stuff to be scared about. Right? And then you guys night pain, persistent pain, neurologic stuff, failing conservative treatment. A again, this is like a plug. You've done all the right stuff. You know, you've seen them, you provide the reassurance, we did an anti inflammatory, we got some imaging studies, you did some therapy, you're like, I don't see anything. You guys wanna come down Charleston just, just see the, see the p or the team and kind of have a second set of eyes type of stuff. That's totally fine. That is OK. That, that's really what we're here for. Um And that's really, I mean, we're lucky that, that we're allowed to provide that context and reassurance as a specialist. All right. Last one. Can you take a look at my kids flat foot? Love this stuff, right? His dad, dad is really flappy. I'm worried. She's, and she's gonna end up like her dad and she's gonna need a bunch of surgeries just like her dad, just like her dad. She's not really painful, but like this is just like pretty painful on my eyeballs like my kid, you know, grandma says her ankles are rolling in and my mom is really bothering about this. She started playing pickle ball, right? My mom started playing pickle ball and she said there's some brace from some of her friends that we need to do. And so like, can you look at my kids flat foot like this? Like this is all like from this is why they're called case files. Like these are all real things that people tell us grandma on the pickle ball. I love it. Ok. All right, cool. So here she is right. So here she is during the gate cycle. And again, we just like our first case. Again, we can be very thoughtful. We can be very intentional. We can be very specific as we look at her in the gate cycle. So let's look at the first one on the left, right as we start here be like uh ok, she is pretty flat footed, right? She is pretty flat footed, but her gate cycle looks ok. Right arm cadence is ok. Shoulders are level ham with the skirt is level normal knee range of motion. She has a heel toe gate. Now you can see here right left, right left, she pushes off nicely. She does have some flat foot, but I don't know, she kind of pushes off, you know, can you like see her on the corner? Is there a little bit of an art that's coming around type of thing. Don't see any skin issues going on. There's no asymmetry, there's no limp. I don't hear anything. Totally weird. But, uh, I believe you, she's got a pretty reasonable flat foot. Ok. And here she's in stance, right? Like dang. Ok. So maybe grandma was right. Maybe the pickleball story was right. You know, don't ever, don't ever validate a grandma. Right. Don't ever validate grandma. Right. Right. So, but, but we can certainly see. Right. The doctor term here. Sliva. Right. So she's got this modest pez vagus. We can see the hind foot is in valgus. You can see there, at least on the right side, kind of like the quote unquote, the too many toes sign that kind of lets her toe is pointing out there if you will. Uh, so there certainly is an appropriate diagnosis of planovalgus. But your exam looks ok. Right. So there's no, there's no Cali or ulcer there along the mid foot. You know, we, we have the kid here in the resting position, shoot arch looks pretty good right there. Right. It doesn't look like it's all that rigid. Maybe the achilles is a little tight but, but then all the other weird stuff, the scary stuff, the Bugaboos, the things that go on there, there's no spasticity, there's no contracture, there's no asymmetry. You don't see any clonus, you know, gate exam looks ok, skin looks ok. Maybe the achilles is a little tight, but like the rest of the kid checks out resting gravity position looks good. And then here we go. So now we're on to rise, right? And so this is really cool. So, and this is a really helpful physical exam for that grandma, right? For that reassurance regarding the flexible nature of the child's flat foot. So we see here as we come up on toe rise, I mean, they're in the resting position, kids look, looks pretty dang flat, they're on the right, doesn't it? But then you can really see the long dual arch normally develops when we come on toe rise. So that's a really reassuring thing in the setting of resting gravity position and then toe rise, we can tell we could almost universally tell the family this is a painless flexible flat foot that likely will not have any prognostic issues. Like 1 to 2% of patients based on epidemiologic data will actually have pain associated with their flat foot. And those are the Ortho bug boos, right? Those are the neuromuscular and the tarsal coalitions and the spastic perennials and all the other stuff that like that's, that's just not your not your average world, right? There's no pain, no pain, no pain. Most common ideology is gonna be a painless flexible flat foot, recons on toe rice. And so th this is a this is a great, great, great slide. Again, you see tons of toddlers with flat, you probably see more toddlers with flat foot, right? Than you see like seven and eight year olds, right. Insert grandma, right. Insert grandma again, right. We see lots of toddlers with flat foot. But again, so like 97% of 18 months old, but then look at the numbers. So we know the longitudinal arch develops over time. By the time we get to age 10, only 4 of kids are gonna have any sort of flexible flat foot. So this is a great slide to council families that there is a sort of step wise improvement in the characteristic of the foot and the development of the media launch to arch. So that this is your reassurance that nothing bad is happening. Nothing scary is happening. The exam checks out, resting gravity position, checks out and you can tell families, ok, cool. This will probably go away over time. Let's just watch it together. And so where do you wanna be on the treatment ladder? Right. And so step number on the treatment ladder, right? We've talked about it all morning long gobs and gobs of reassurance, right? You're gonna be ok. You're gonna be ok, you're gonna be ok. But for many families, that's ok, especially for your three and four year olds, right? You can tell them, we look at that data once we start to hit 5678 and we're persistently flat footed or so, maybe we'll engage with families a little bit more in the active treatment. We'll talk about that in just in just a slide or two. But again, gallons and gobs of reassurance that two slides ago that this thing is gonna get better and less than 5% of kids age 10 will have some sort of flat foot. Ok. Should I get an X ray before? I Senator Murphy? Pro, probably not, again, painless and flexible. There is a really low diagnostic yield for a rigid flat foot. Yes. Right. If there's rigid callous ulcers, pain, things that go bump in the night, weird stuff like that. Yeah, I think an imaging study is totally appropriate. But I mean, you guys remember from Ferris Speller, you know, when he puts the car off the back, he's like, do you want that kind of heat from Morris? I'll take that heat, I'll take that heat, right? So you guys don't need to get an X ray. I'm happy to get an x-ray or at least provide that extensive reassurance that family that know your child does not need an X ray. Let's save you the, let's save you the copay. Let's save your child the radiation. So probably no, no need for a film if you will. And so again, from a first case, right? Stupid anatomy, right? Anatomy is always getting in the way, right. So again, the triceps, the gastric anemia. And so the idea here is that, that maybe there is a little bit of tightness, you know, at this achilles complex and that tightness at the achilles because the way it inserts in the calcaneus is driving that kid to a little bit of, we can kind of see on those yellow annotations there, you can see the hind foot a little bit of a and so maybe that really is from a somewhat tight achilles and so you can at least offer that to families as your initial salvo, right? If you, if the goal for today was cool. Nothing crazy is going on again. Amen. Spiritual. Hallelujah. Amen. Spiritual hali nothing crazy is going on. Your child is a flexible flat foot. But if you want to be more active and you wanna feel like you're being more aggressive and more ownership for your child and that type of stuff. Yes, absolutely. Again, there's not much in the way of harm for a P T program for most kids. Again, twice a week, for six weeks is kind of the opening thing, but again, kind of modulate as much as you want to heal cord stretching, proprioception, dynamic stuff. I tell families confidence, building, strengthening the parameters. That type of thing inserts vigil, I have vigilante justice against inserts. So kind of like durable medical equipment too, right? I don't know if anyone has the kid who's been charged for a fracture brace, but you get the bill. Like, what do you mean? This is $300? What do you mean what I mean? It's $3. So, so anyway, so vigilante justice against. So over the counter inserts are truly a child with a painless flexible flat foot over the counter inserts are all that that child needs, right? So I'm sorry. Good foot store, I'm sorry. $300 custom court board, NASA technology type of stuff. You probably don't need that. And there is reasonable data that supports the over the counter inserts are non inferior or equivocal to a custom orthosis or a U C P L or an S M O or that type of stuff. So at the very most I have them go to their, their local Walmart Super Center, the doctor Scholls the Peter bar graph again, $2025 I'll go on Amazon with families a lot. We sort of just look at Amazon and say go shopping for the model that you like. But 2025 bucks again here, Ankle International 2007. I'm sorry about the the reference. But yeah, there's pretty good data that over kind of inserts are appropriate for these types of kids, but again, very similar to the toe walker. There's really no data that tells you that a pediatric flat foot will preclude any either podiatric or orthopedic foot and ankle condition. Ok. Again, so things that go bump in the day, kids with pain, right, painful flat feet, those are probably reasonably concerning rigidity, right? If you see it does not reconstitute during the gate cycle does not reconstitute and the resting gravity position does not reconstitute when they're in tow, rise those types of things. And then the other stuff, right? Asymmetry, skin lesions calluses that type of thing as well. I put sports overuse stuff on there but email me if you wanna talk about it. It's just, it's a very diverse quagmire. I chose not to go over it today. Plus I wanna give, give you guys so we stay on track type of thing. But um sports over use is something we see very frequently. I'm sure you do. So this is fun, right? I I alluded to it a little bit earlier but, but truly the ra ra surgeon and why is the profanity insert word in my office? And this does like no, like that's fine. Just send it right. Just send it whether it's me or our P A or N P. If there's something that you don't like about it, it doesn't smell right. It feels weird or the family is just wearing you out, right? You've kind of had enough and I've like, I did the ladder, bro. Like I did your ladder, bro. I'm like, they keep coming back, you know, like, I mean, I, I truly mean, like I look, I look at the pro like I, I talk at the film medicine thing too, like the diversity of stuff that you are asked to see and manage is remarkable. And so again, that's not brown nosing, that's not sycophantic, but like, please send it and send it films are ok. We probably kindly ask probably to avoid advanced imaging type of stuff before we see the child, you know, C T scan MRI. But yes, like this is why we're here. We are so fortunate that my entire job is just children's muscular skeletal medicine. So if it doesn't smell right, just send it along, you know, it's all good. So these are the anomalies that live in my house, you know, 886 and two, just so much right now. Um And this kid goes in almost any talk. I do. So I have a two year old. This kid is two like this kid is two. Take a picture of this, write it down, truly, like, truly, truly, truly, if it's weird, email me, text me like we are on the same team like we work together, you know, we are like incredibly grateful for what you do. So uh with that, I'll close. If you wanna see the references, I have all of them. Like thank you so much for your time. I'm more than happy. Oh, here we go. Thank you. Should we do a couple couple minutes of questions? Get you back on track. Let's do four minutes of questions. We'll get back on track. Ok. Click hit 10 week old ultrasound at that old six weeks frog frog like hip x-ray usually kids who are. You're right. So 3 to 6 months is when we start getting plain x-rays. Um for your case, if you want to get an ultrasound and know that you save the kid the radiation, I think that's ok too. You know, our ultrasound techs are pretty good. Um which is better for hip dysplasia. Ultrasound at six weeks. Yes. So ultrasound at six weeks. Again, radiology, but image, early image often image, frequently image for all right. So, but yes, again for you, right? It's a six week old. It doesn't smell right. It's a clicky hip, there's data that tells us yeah, just ultrasound it and be done if you have a local ultrasound community great and send it on the disk to us if you're like, just get it all done in Charleston. That's now um that type of thing. Um But I would get an ultrasound in six weeks and then you just put the dang thing to bed. It's done, right? And then it's just over, you know, there's no dysplasia. Your exams rock solid. If you have a normal ultrasound, you know, the ultrasound is not gonna get any worse. So if it is that snapping, so type of thing, it's just box checked, move on to the next back pain or whatever. God bless you guys and what you do, right? So sports culture now get like a minute of philosophy. Yes. So kids are pushing themselves more and more are we seeing more and more sports over use type of stuff? Yes. Do I feel like I am escorting you on your sports journey, not doing anything but collecting an R V U along the way. Yes. But again that philosophy, you gotta let the kid, it depends on the age of child. Let let the child kind of auto modulate themselves. They wanna be on the team. So go be on your softball team. Do your travel team work on batting, work on stretching, work on conditioning. Still be on the team. Your mom paid the, your mom already paid the fees for the copay for the thing. Like go ahead and do that. So, um I let them participate, I don't pull kids out of sports and I let them kind of make that decision on their own stiff ankle, high leather shoes and toddlers, you know. So Dennis Winger in, in San Diego, a actually in the conjunction with the podiatrist published really good data in the early nineties that said that shoe type and wear really doesn't have an impact in terms of the development of the longitude, the, the the natural history of the development of longitude, there's no acceleration of that. So if you wanna put them at the joke, I tell families, you wanna put them in Walmart flip flops, you wanna put them in Gucci Loafers, you wanna put them in Tory Birch, you can put your kid in whatever you wanna put them in as long as it fits your budget and you like the style. But there's really, there's, there's, there's data that says that there's no change in the development of the long arch of the foot with, with uh type of shoe wear, uh skinfold asymmetry as a useful. Yes, it still is. Again, you see skin fold asymmetry, then you know, at least your radar is up, right? You may spend an extra 30 seconds really rolling that hip back and forth on that exam. But I would say 100% any clue and indicator that's like this is not a normal hip or this hip doesn't feel like kind of all the rest of them. Absolutely. 100%. I would still use that, that physical exam finding for sure. Any role for custom orthotics or podia referral. Yes. So, Ron Ravenel is my podia colleague. I'm very grateful that he's part and we have lots of podia friends. Some families kind of like how some people will see a chiropractor versus an orthopedist for back pain. They'll see a podiatrist versus a foot and ankle orthopedic for foot pain. I, I, I think that's ok based what we know on the literature that I support a day. There's not much role based on Cochrane review for a custom orthotic that a that a doctor Scholls is ok and non inferior. But some, again, there's that thing, there's that people think they need what they need, right? I have a fracture. I need a cast, right? Or I have this, I need this. So if that's what you think that, that, that, that's ok. Stretching flat foot, a little tight, stretching grandmas mean flat. I agree completely. Just stressing grandma, stressing grandma. OK. So repeat the 32nd neuro exam and then I probably should let us kind of stay on track if you will. So um can we just Gina you? OK. Let's just go back. Can we just go back to that slide or did we die? Computer died. Close me, I've been deleted. Swipe left, red trash can. Murphy's done. I would, I would delete me too. You're good. You're good. All right. So, so 32nd. Oh, perfect. Awesome. Thank you. Thank you. Thank you. Thank you, motor and reflexes, right? Motor and reflexes. Really? And you're looking for asymmetry in either of those. There's a back pain sensory. Here we go. All right. Ready. S one push down on the gas pedal, gas truck. S one push on the gas pedal. Show me a thumbs up to your big toes. That's E H L. That's your Dorsa flexor house. As long as L five ankles go up is L four TV, ankle stays up. L four T L L three quad kicks out L three quad kicks out abductors or here's your hip flexor at L one. Excuse me, hip flexor abductors come out, abductors come in. That's L one and L two reflexes. Patel tendon reflex is Patel tendon tendo achilles, tendo achilles. And then your long track signs clonus, make sure you have any beats of clonus. And then really rarely we'll see, but a little flick up with the thumb. No fanning of toes, flick up with the thumb. So with that, I'll close, I'm happy I'll stick outside for a question too. But like, thank you. Thank you. Thank you for the invitation. As always. Published April 3, 2023 Created by
