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Hypersensitivity in 11 y.o

Discussion in 'Pediatrics' started by MelbPod, Sep 15, 2009.

  1. MelbPod

    MelbPod Active Member


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    Hi paed pods... I need a bit of a hand,

    I had a mother bring in her 11 year old boy for a 3rd opinion of his feet.
    They had been to a podiatrist when he was 5 y.o and issued orthotics, but 6 months ago had been told he didn't need them...so the presenting concern to mum was does he need them or not. I thought there was mre going on..

    History:
    Prem birth at 30 weeks
    Reached most milestones at normal age, walking 15 months.
    at 5 y.o was seeing paed OT for issues with fine motor skills, mother says great improvement, no longer an issue.
    Pt. describes general foot aching from heel to forefoot.
    Footwear appropriate school shoes and cross trainers.

    When questioned about foot pain, he described it as when he stands on the hard ground ( I was thinking along the lines of heel bruising, severs)

    His foot is a typical 'tripod' type with minimal surface area contacting ground.
    tight gastroc soleal, but able to bring heel to ground.
    weightbearing stance fairly normal pronation/supination.

    Reflexes normal

    GAIT ASSESSMENT:
    on gait there were moments of toe walking, otherwise all was normal.

    After questioning mother she said he has been doing this more and more over the past few years, and the patient said it is because the 'hard ground hurts his feet' and it has made me beging thinking about hypersensation?

    I have to admit I am not fully up to scratch with tx of paeds, but would love any advice for this boy and management options.

    Thanks,

    Sally
     
  2. Hi Sally,

    A few questions
    what is the patient weight ?
    By tripod I guess there is a forefoot valgus is there a plantarflexed 1st ray?
    is there a FF equinus ?
    ROM of stj mtj 1st ray and 1st mtp joints
     
  3. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    Sally .... think back 3 years to that paeds lecture on sensory integration.
     
  4. MelbPod

    MelbPod Active Member

    Patient is about 32 kg

    Tripod - weightbearing 5th mtpj, 1st and heel. yes plantarflexed ray
    no forefoot equinus

    ROM above joints normal.


    Craig: lots of theory, little practice.
    I was hoping for some clinical advice if anyone has dealt with sensory integration issues?

    Thanks
     
  5. robert bijak

    robert bijak Banned

    Any blood tests or x-ray results? I'd re check those reflexes there may be a little occult cerebral palsy or other neurological cause to the hypersensitivity. Any Pb exposure or Vit C defiecency? How's the glucose? The cavus foot and tight grastoc may be Dejerine-Sottas, friedrich ataxia, spinal canal etiology. Treatment should be specific for a diagnosed condtion. Would appreciate a follow up. thanks robert bijakdpm USA
     
  6. Sally:

    Think Sever's disease before anything else in this age group. Treat the boy with over-the-counter orthoses with heel lifts initially and have the boy start gastrocnemius and soleus muscle stretching 3 times a day and always have him wear shoes with no barefoot walking/running since the rest of his complaints are most likely mechanical in nature, until proven otherwise.

    When you hear hoofbeats, think horses not zebras.:drinks
     
  7. robert bijak

    robert bijak Banned

    Treating as you say without laboratory investigations and X-ray 's is negligence in my opinion robert bijak, DPM<DAABPS
     
  8. aliciaj

    aliciaj Member

    Hi Sally,

    Sorry I didn't see the topic, I am a little late coming into the equation.

    This little guy sounds fun! Sensory Integration would have likely been assessed or at least looked at by the OT that he previous attended. In the sense of a patient presenting often they might have difficulties with texture- removes footwear, only wears socks with no stitching, pulls their laces really firm, won't wear really tight clothing eg bathers or tights, spins their body around alot, or even avoids people touching them. They might seem really stimulated by surfaces, may put things in their mouths, or even doesn't like walking on sand.

    Generally they don't explain their difficulty as pain, though they often have a fantastic coaping mechanism of avoidance.

    I have to agree with Kevin in this age group I tend to think Sever's in heel pain. X-raying is not going to give you a diagnosis of Sever's though it may rule out any nasty like fractures or tumours. I generally don't x-ray straight away, if they inital treatment has no positive effect then imaging could be an option.

    Was there any Hamstring tightness? Was there a positive thomas test? To go along with the tight gasctro muscles. Do any of the other family member have the same foot structure? Completing laboratory investigations may be premature, have a look at family history first.

    Hope that helps

    Alicia
     
  9. robert bijak

    robert bijak Banned

    Not to be troublesome or argumentative, I do find the treatment approach tentative. Perhaps I'm too aggressive. But, I feel while your waiting to see how your treatment is working the little guy is in pain. I don't want to be in pain for an hour let alone weeks, but that's the art and personality of the practitioner I guess. robert bijak,dpm
     
  10. Bug

    Bug Well-Known Member

    I think Kevin has the right approach here in that think Horse, not Zebra's. Unless there is no other joint pain, the child is presenting as a healthy child with no family history of anything suspicious then blood tests are a tad premature. But, don't forget your squeeze test for Sever's. His description of pain is very typical of gastroc soleus tightness in kids.

    I would would also add ice massage so the child "feels" like they are doing something to help the pain go away. At 11, neurofen or even topical voltaren can be used (check your dosage/application etc though).

    At the same time though, I would have another look at everything Alicia mentioned to ensure there isn't underlying Hemiplegia (CP) with the group of muscle tightness. Reflex testing is also a must, patella and plantar. He is out of the age group that participates in a prem follow up study therefore won't have had these assessments for a while. Anecdotally, mild CP can become more problematic at this age of rapid growth. How 11 is he? 32kg is a bit of a skinny mini for the older 11 year old also so I presume he doesn't have a lot of body fat also.

    I think I'll just run around after Alicia saying "What she says!". SI, while a valid concern in prems, generally isn't as big an issue by this age. They have generally learnt positive or negative coping mechanisms and tend to present more as a quirky kid. At this age, unless they have learning or intellectual disability, I haven't seen tactile defensiveness described as pain by the child.

    Good luck!
     
  11. Airlie

    Airlie Active Member

    Hi
    In some recent reading I came accross this article by Angela Evans, Growing pains: contemporary knowledge and recommended practice, in journal foot and ankle research

    http://www.jfootankleres.com/content/1/1/4

    it has a brief paragraph suggesting some low pain threshold in children...

    It definitely provides some extra food for thought.
    The other thing I remember from paeds at uni was a link between toe walking/plantar hypersensitivity and Autism Spectrum Disorders...and just this afternoon have seen a woman whos son fits this category (fyi, he is now an adult and continues to toe-walk with no pain)
     
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