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Hi,

I’m a first time post-er, but a long time reader!

I have a 6 year old boy who presented complaining of pain in dorsal interphalangeal joints of both halluces, left worse than right.

There was pain in the interphalangeal joint on plantarflexion of both halluces and on palpation of dorsal interphalangeal joint, left worse than right.

No pain on dorsiflexion of interphalangeal joint.

Normal range of motion of interphalangeal joint both first digits.

Pain levels are 8-9 out of 10 on palpation and on plantarflexion, keeping in mind this is a 6 yr old boy.

Painful when walking and especially when on standing on tip-toes.

History of pain has been present for around 6 months, progressively getting worse, however only in the last month has it become an issue, especially after exercise which most recently has been after Karate (barefoot exercise).

No history of trauma or injury to either foot in this particular area.

He has bilateral moderate rearfoot pronation (approximately 6-7 degrees everted) and mild intoeing of both feet.

Treatment has consisted of rest from offending activities (sports/Karate), icing twice daily to the area and sent for x-rays of foot.

Treatment also consisted of orthoses which will aim to correct excessive pronation and intoeing, these orthoses are yet to be issued (issue date in 1 week).

The x-rays are attached, focusing in on the left medial interphalangeal joint of the great toe.

Xray report reads as follows:

Left Foot
There is a dysmorphic interphalangeal joint of the great toe which demonstrates a spur at the head of the great toe proximal phalanx medially and joint space narrowing, possibly due to a partial fibrous union between the phalanges of this joint medially. It is uncertain, whether this is due to developmental abnormality or related to previous injury. No other joint nor bone pathology demonstrated. No evidence of fracture.

Right Foot
The bones and joints appear normal. This is no evidence of fracture.

Any suggestions, is this something that warrants examination from a surgeon?

Your help would be greatly appreciated. Thank you.

Attached Images

Xray1.bmp (225.1 KB, 30 views)

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In light of the excessive pronation, could functional hallux limitus be present in this patient?? I believe that can lead to b/1st IPJ having to hyper extend to help with sagital plan progression. This may cause pain on palpation of the dorsum of the joint, and pain in passive plantar flexion. It may fit with the sporting activities (especially Karate - barefoot and running around) and the excessive pronation. In which case the insoles should help.

Not really heard of FnHL in kids, but then again I don't see more than a handful of kids.

Just my tuppence worth.

Sam

It is very unusual.

Certainly detensioning the Planter apeurneurosis should reduce the need for extension in the IPJ and help with the pain. Whether that is the CAUSE of the pain is impossible to say without seeing the patient, however it seems unlikely to me.

I would be thinking in terms of either injury (always possible with Karate, Sieza can really smart if you hold it for long) or congenital defect. Any family history?

Apart from the "standard" orthotic to control pronation and damp the windlass i would be considering a Gait plate. I would definatley consider a surgical opinion, not necessarily with expectation of surgery which is always complex on growth plates, but for the extra experiance of radiographic analysis. I'm sure one will be along here shortly.

Regards
Robert

Hi Mickey:
You were very complete in your explanation.

The question is whether this is Bilateral or not. He complains of pain in both however his X-ray was normal on the right.

If the Right appears normal and his symptoms are questionable (tough on a 6 year old be be accurate) then I would suggest the changes in the left IPJ is post traumatic in nature (perhaps microtrauma perhaps not.)

If you feel it is biomechanical in nature then certainly treat accordingly with an Orthotic of choice. ROM exercises my help as well. Surgery would be way down on my list of treatments for this patient.

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

just a word of warning here if you are going to immobilize the hallux with a full length rigid plate be certain that the shoe your client is fitted with has a mild rocker sole otherwise you may change his whole gait and create other problems

__________________
David Sutton
C.Ped.CM.Au
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