Bilateral Pronatory Syndrome Greater in the right foot – additional opinion
Short Summary

10-year-old female with pain and swelling of the right foot was diagnosed bilateral pronatory syndrome. The specialist recommended foot surgery for the lengthening of the Achilles tendon and application of retrograde endorthesis screw. The expert disagrees with the necessity of this procedure, and suggests differential diagnosis and conservative treatment that includes pain killers, soft shoes with soft insoles inside and mild elevation of the medial longitudinal arch of the feet.

Patient's Questions
1)    Do you suggest further diagnostic work-up?

2)    What therapy would you recommend?

3)    Centers of excellence in Italy?

4)    Prognosis ?

Medical Background

Sex: F, Age: 10 years
Following the onset of pain and swelling of the right foot, a specialist visit was performed by 04/2008 during which a diagnosis of bilateral pronatory syndrome, affecting the right foot to a greater degree, was made. Therefore, the physician suggested:
-          Dorsal plantar and latero-lateral x-ray of both feet in full weight-bearing position;
-          Plantar orthesis with a 16 mm dome and hindfoot supinatory wedge;
-          Hindfoot-restraining shoes but of soft materials

On 05/2008 weight-bearing x-rays were taken of both feet and the report reads as follows: “Normal morphology, structure and trophism of the bone segments under examination. Tarsal and forefoot joints are normal bilaterally. Non-flat plantar arches”.
A follow-up visit with confirmed the previous diagnosis of bilateral pronatory syndrome greater in the right foot. She recommended:
-          Right foot surgery for the lengthening of the Achilles tendon and application of retrograde endorthesis screw (calcaneo-stop surgery).

-          plantar orthesis

-          hindfoot-restraining shoes
According to Dr X, the avoidance of said surgery might lead to frequent and severe pain, swelling, valgus foot (for which surgery is not advisable before age 20, after full growth) increasing of foot pronation etc. Also, in Dr X view and contrary to the x-ray report the patient’s feet have low arches since the tilt angle does not reach 10°. Consequently, she endorses surgery of the right foot complemented by the application of a short leg cast for 1 month.
4 months later, the same procedure should be performed on the left foot.
Given the patient’s age, the doctor believes shoes insoles might be beneficial but do not correct the condition.
A further orthopedic specialist, who was consulted, deems the use of a shoe insole more appropriate for the time being while the surgical procedure might be reconsidered at a later date on reassessment of the clinical evolution of the condition in time.

Expert's Opinion

The patient is 10 years old. Her x ray pictures are normal and I do not see any sagging of the medial column. I agree with the report of the radiologist and disagree with the statement of Dr. X. about the result of the x ray pictures.
It is true that in severe cases of pronation and flat feet, one should consider elongation of the Achilles tendon and using arthroereisis technique. However in such severe cases the x-ray pictures should show the sever deformity. It is contrary to the pictures that were sent to me.
I have a feeling that the diagnosis is different from the one that was suggested by Dr. X.
 
If it is possible to send me photo pictures of the child feet, standing from the front and from the side, it will help me to be more accurate with my diagnosis.
 
The differential diagnosis can be: beginning of Coalition symptoms. I need to know the range of movement of the Sub-Talar joint. It can be also some general problem like a beginning of a rheumatic symptom. In order to progress in that direction she has to be examined by a pediatrician and do some specific blood tests.
In the mean time, I suggest pain killers and soft shoes with soft insoles inside and mild elevation of the medial longitudinal arch of the feet
 
Regarding a center of excellence in Italy,
The patient can find help at:

Prof. Sandro Giannini
 
 
 
 
 

I saw the pictures and now I am more confident to say that the Dr. X that wants to operate on the child feet is wrong.
The pictures show normal feet with slight valgus heels and flat feet at the "normal" range.
I am more convinced now that she should go through the tests that I recommended.

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