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We spend so much of our time dealing with the science of medicine, but sometimes there are things we just don’t know the answers to yet. Of course, this is pretty obvious considering the tens of thousands of new journal articles published yearly throughout the medical literature.
- What is the cure for cancer?
- Why has the incidence of asthma increased so dramatically?
- What causes Alzheimer’s disease?
- Will we ever stop the aging process?
Podiatric medicine also has its unanswered questions — many of them controversial simply because we have not been able to explain them definitively.
Here’s one, for example. I saw a 12 year-old female patient a few weeks ago. Despite her complete lack of any symptoms, her mother brought her in for evaluation of bilateral flat feet. You know where this one’s going!
“Does my daughter need any treatment for her flat feet?” the mother asked.
After a full biomechanical examination in which I failed to elicit anything significant beyond a flexible transverse plane pes planus deformity, I spent the next several minutes counseling them. We discussed that there is no strong research evidence that recommends treatment of asymptomatic flexible flatfooted patients, and that any recommendation comes purely from physicians’ experiences. I recommended watchful waiting since this otherwise normal patient had no activity limitations, a family history of asymptomatic flat foot, and a not especially impressive physical examination. Those of you who are business-oriented will of course chastise me for not at least putting her into a pair of foot orthoses. And you might be right! However, practicing evidence-based medicine requires me to take my experience, the research, and my patient’s values into consideration which led me to the above conclusion.
Don’t agree with me about the research regarding asymptomatic pes planus? Well, here’s my only argument from the scientific literature. This is a direct quote from the Cochrane Database:
“The evidence from randomized controlled trials is currently too limited to draw definitive conclusions about the use of non-surgical interventions for paediatric pes planus. Future high quality trials are warranted in this field. Only limited interventions commonly used in practice have been studied and there is much debate over the treatment of symptomatic and asymptomatic pes planus.”1 |
Now, on the other end of the spectrum comes my own son. He’s currently 6 years-old and inherited my flexible pes planus foot. Actually, he has a partially compensated metatarsus adductus (i.e. a skewfoot). Based on my own history with foot pain (severe, daily, and unremitting – I’m clearly a surgical candidate after having myself been in orthotics since the age of 8) and some currently minor symptoms, I am treating my son with a pretty aggressive pair of UCBL-type orthoses. EBM aside, the issue becomes much easier when patients are symptomatic.
Now comes the OTHER pediatric pes planus unanswered question: should these children undergo early surgical correction to correct the biomechanical faults? I’m not sure if we’ll ever know the answer to this question since creating a high quality ethical research study is virtually impossible. Therein lays our dilemma. We need to treat (or maybe not treat) our patients, but some of these issues will never have a satisfactory answer because we can’t create good research studies.
We’ll just have it leave it in the “unanswered” category along with some of these others: do bunions cause hypermobility or vice versa; which joints are involved in metatarsus primus elevatus; will we ever “reverse” Charcot (much less predict it)? There are so many more unanswered questions. That’s why they call it “practicing” the art of medicine!
Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum.
Best wishes.
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
References
- Rome K, Ashford RL, Evans A. Non-surgical interventions for paediatric pes planus.
Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD006311.
DOI: 10.1002/14651858.CD006311.pub2.
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