A rambling blog by Cylie Williams
Are you an Henny Penny (aka THE SKY IS FALLING), a Lenny Layback (aka Nothing To See Here) or Malcolm in the Middle when it comes to your treatment style? Reflecting on how we interact with our families, helps us to be better practitioners.
Clinic day and in comes a family, and the child has curly toes. The parents are seriously concerned that this will cause pain and deformity in the future, unsure if it will impact on the child's running, jumping shoe fit? Parents really want the best of their child and how can we correct this THING? Like all good clinicians, we all sit and listen and hear the worry that these parent have.
The next step though, what we do about it. Do we launch into all the different treatment options, talk about buddy strapping, massage, a splint of some sort, surgical options and the evidence on long term impact (HINT….there is none). After this, the parent is signed up to a treatment regime that is going to take 10-15 minutes every day and then if they miss it, have that niggle of guilt that parents carry around when they are meant to do something but just can’t fit it in. The guilt and worry they are damaging their child for life because they didn’t do what a health professional told them to do.
Or we sit back, confidently smile and remind them that children and their associated parts come in all shapes and sizes and this is just one of them. If down the track, the nail changes, the child gets ongoing blistering on their skin, we might try something but really….no worries.
Or do we sit in the middle, honestly present the facts and evidence in a way the parents can understand, let the parents know they can give it a go, but if they don’t, not to worry about it. Taping is easy but it’s also a pain when you are sleep deprived, have a wriggly baby or a child that always manages to get in and pull that tape off.
It’s my opinion that this is the best approach to have with many of the conditions podiatrists commonly see.
- Intermittent Idiopathic toe walking in toddlers. Kids with no gastroc soleus tightness, sometimes they toe walk, sometimes they don't. No worries, maybe try some heavier shoes, come back if things change and not get better.
- Flat feet, no pain, keeping up with all the other kids. No worries, come back if things change
- Intoe walking, some tripping (but what kid doesn’t), all angles within normal ranges for age. No worries, come back if things aren’t changing.
- Metatarsus adductus, fully flexible. No worries, come back if things aren’t changing.
- Piezogenic papules (you really need to remember this one, they are lumps, google them). No worries, lots of kids and adults get them. It’s like a hole in a orange net bag that keeps all the fat in, no worries. Come back if they get sore.
Many treatment strategies for kids are based on our experiences, both in the clinic and in life. The more of one condition we see or are exposed to, the more confident we get, but also, the more pragmatic we get about about treatment pathways. The experiences of seeing things differing in severity may also impact the language used and treatment plan. Seeing a patient with curly toes straight after seeing a child you suspect as having a neuromuscular condition, may impact on how you look at those curly toes and think…you just don’t know how good your child has it!
When teaching podiatry students, the classic question is often asked “But what if we do nothing and they go down the road and get orthotics from someone else and we’ve said not to”. So what?
You know, treatment is reassurance, treatment is advice, treatment is sometimes watching and waiting, sometimes footwear advice, stretching, taping, referral, orthotics and lots, lots more. Most of all, treatment is understanding the evidence behind the treatment and presenting it in a way that a parent understands and then is able to make an informed choice about what they want to do with their child.
Sometimes that means, as a clinicians, you need to run around and making everyone listen (aka Henny Penny, the sky really is falling and we all need to fix it) or just sitting back and chillin’ as Lenny Layback.
We just need to check ourselves, trust in the evidence and think about our language and impact of our treatment on the whole child and family and most often aim to be Malcolm in the Middle approach.