September 18, 2019
What Happened to Scoliosis School Screening?
By Rosemary Marchese (Physiotherapist, Schroth and SEAS certified for Scoliosis)
Idiopathic scoliosis is a three-dimensional deformity of the spine. However we always like to remember that we treat the person, not just the spine. Often these patients have feet problems too. It is a major reason that we have a podiatrist onsite to ensure that patients get the very best holistic care from our team. Here, we have asked him a few questions about his recent experiences seeing patients who require foot care but who also have scoliosis.
Initially, we look at the EOS scan observing any signs of anatomical or functional limb length discrepancy (LLD). If identified I can make sense of some biomechanical deviations that may be seen when I begin the gait analysis. We continue the consult by conducting a thorough biomechanical examination specifically looking at how is the Scoliosis is influencing the patient’s biomechanics and vice versa. We also look at the base of the footwear looking for any asymmetrical wear patterns. It’s common to see asymmetrical wear patterns in patient with Scoliosis due to the biomechanical changes influencing the foot and ankle.
In many cases we see patients with Idiopathic Scoliosis have a limb length discrepancy (LLD). We also see knee medial rotation, anterior pelvic tilt and one-foot rolling in more than the other to compensate for a LLD. This constant driving of the first ray (first toe) into the ground, whether this is on the longer or shorter side, will contribute to an early breakdown of the first metatarsophalangeal joint (MPJ) (big toe joint).
A clear analogy is the front end of a car. If it is not aligned properly, the car will constantly pull to one side. When this occurs, repair is needed. Unfortunately, our patients do not always realise they need repair and continue to function and cause further damage. In less severe cases, maybe only the front tires will wear unevenly. However, if one just replaces the tyres, this is analogous to treating only the symptoms. After several hundred miles, the exact thing can happen again.
Another analogy is the foundation of a building where symmetry is critical. You would never want to build upward on a crooked foundation. That would be a cause for instability, breakdown and disaster. The bottom line is that mechanical symmetry is critical for a machine to run smoothly and efficiently, or for a building to be stable. This is no less important for the human body.
In older patients who have not had conservative treatment we see increased wear and tear on one side. For example, mild to moderate medial compartment joint space narrowing and tibialis posterior tendonitis in the longer leg.
There are many specialties that are forced to deal with Scoliosis and LLDs. We as podiatrists often deal with the condition in the form of heel lifts in the shoe or heel lifts that one can add to orthotic devices. This is often inadequate in fully addressing what the patient needs. Physical therapists with a comprehensive exercise program to address the compensations are also required.
It’s vital we get an EOS to understand the exact amount of the LLD. This should be done yearly in children as the length can change during growth. Placing a heel raise is okay if the foot function is not compensating by excessively pronating or has a history of ankle inversion sprains on the shorter side. If a heel lift is only required, it’s also advisable to have at least a three-quarter length lift and not simply a heel lift. Unfortunately, this concept seems foreign to too many practitioners. For the best outcomes, one needs to raise the entire short side, not just the heel. I advise seeing a sports podiatrist to gauge what is required for each patient.
When there are existing foot changes, we recommend an orthotic to stabilise the foot, reduce the compensation in conjunction with the lift. We will also mention certain footwear recommendation that have enough room for the increased lift and the stable characteristics.
You are right! A recent award-winning study also examined this and concluded that as practitioners we need to check hypermobile patients for scoliosis due to the high prevalence and correlations between the two conditions.
Patients with joint hypermobility have increased laxity in their ligaments. During gait increased laxity causes the joints to move further than the standard resulting in the muscles to have to work harder to stabilise them. In this case we see patients who are hypermobile have very pronated feet, which also causes medial rotation of the knee (knocked knee alignment) followed by an anterior pelvic tilt. It’s common for patients who are hypermobile to experiences symptoms of fatigue and joint pain. Research also shows that hypermobile patients are at an increased risk of musculoskeletal injuries.
I think it’s vital to work with the patients treating accredited physiotherapist, surgeon and GP to stay up to date with the spinal changes. Due to the ongoing biomechanical changes occurring in patients with scoliosis we need to begin with a mild prescription and build up from there. An aggressive change is not recommended in this case. Furthermore, we need to ensure gradually address the LLD and not build it up all at once.
Podiatrist Mo Maarj sees many patients with scoliosis who have feet problems. For more information call (02) 89140508