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Intoeing Toddler

Discussion in 'Pediatrics' started by Canada Foot Guy, Mar 12, 2011.

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  1. Canada Foot Guy

    Canada Foot Guy Active Member


    Members do not see these Ads. Sign Up.
    New Patient...2 1/2 year old male, healthy, toe walking, intoeing and asymptomatic flatfeet...patient in 95th %tile for height and weight, big calf muscles....for the next few weeks, we will do some gentle daily stretches to treat a soft tissue equinus...and then in 6-8 weeks revisit the intoeing....any other ideas ???....

    intoeing appears to be north of the knee...

    CFG
     
  2. Bug

    Bug Well-Known Member

    Any more history to go on?

    2 year olds intoe: See this journal article

    2 year olds also toe walk at times as part of normal development in the absence of tight muscles.

    Without more history to go on, I suggest you have a look at some of the toe walking and intoe threads. Both of these things can be orthopaedic or neuromuscular in origin, the ortho stuff you can wait and watch, but you don't want to be missing the neuromus stuff. Otherwise we could just be throwing a stack of scary diagnoses as you.

    My main concern though - 2 year olds don't have tight muscle in the absence of something going wrong even if they have been toe walking at times. You just need to work out what the "going wrong" part is.
     
  3. Admin2

    Admin2 Administrator Staff Member

    In toe gait threads
    Toe walking threads
     
  4. Canada Foot Guy

    Canada Foot Guy Active Member

    Thanks for input Cylie and to the Admin...

    will gather more pre, peri and post natal history, read article and reveiw threads.....and then follow-up with patient and this forum....thanks! this site is amazing for a newbie foot guy starting out....
     
  5. RobinP

    RobinP Well-Known Member

    Large calves? Always suspect for Duchenne but as Cylie pointed out, history needs to be more detailed

    Robin
     
  6. Hillm2

    Hillm2 Welcome New Poster

    Hi
    I agree with previous posts the intoeing appears to be coming from the hip via your description "north of the knee" and therefore could be a variant of norm (see Stahelli's work on rotational profiling). However the increased calf bulk could be pseudohypertrophy and along with the tip toe walking and restricted ankle dorsiflexion have a far more malign neuro aeitiology, (Duchenne's, Beckers muscular dystrophy,)
    Review birth history, (low Apgar score etc) Family History (maternal side in particular as these conditions are X chromosome linked).
    Motor Milestones (delayed or met), check for a Gower's sign to indicate proximal muscle weakness(proximal muscle weakness could also be a cause of the in toeing due to gluteal tone loss) , Patellar reflex, and try to organise a blood test for CPK to rule out anything nasty if unsure refer to paediatrics for medical consideration.

    Hope this Helps
    Regards Matt
     
  7. BAMBLE1976

    BAMBLE1976 Active Member

    Hi

    It could just be femoral neck anteversion which is common in this age groups and slowly derotates as they get older. If you lie the child prone with knee flexed to 90 degrees, palpate the head of femur and internally and externally rotated and hold it at the point where the greater trochanter is most prominent. Now check the angle that the shank i.e. tib and fib are in relation to the vertical. If the foot is moved laterally from the vertical then this is positive for FNA and will lead to an intoeing gait.

    regards

    Barry
     
  8. Alex Adam

    Alex Adam Active Member

    If the child was late in delivery it may be the subtalar joint is in an uncompensated position, thereby producing an internal torsion in heel strike phase. C section also produces the inturned effect due to the lack of antivesion throught the birth canal.
     
  9. Bug

    Bug Well-Known Member

    That's a big call given that 30% of babies in Australia are delivered by c section, elective or emergency. I think it there may be some rotational impact if the neonate was a footling or a frank breech but a true breech has the hips in an external position during formation. A head down, bum up presentation with legs crossed, there is no reason for an internal force to be placed on the hips nor for the birth to change that. The birth canal with 10min-3hours of second stage labour won't change the osseous development that took 40 weeks to form. Happy to be proven wrong but not a theory I have every seen or had presented by ortho colleagues that do all the rotational surgery.

    I'm still with Robin and more concerned about large tight calves in a child this age than intoeing which is most often benign.
     
  10. Canada Foot Guy

    Canada Foot Guy Active Member

    Thanks to all for your excellent input..much appreciated ...will follow-up with you regarding any further progress on this case...:)

    cfg
     
  11. BAMBLE1976

    BAMBLE1976 Active Member

    Hi

    The most important thing if you are worried there is neurological involvement is to refer to the paediatrician!!!!

    Regards

    Barry
     
  12. Bug

    Bug Well-Known Member

    Why Paediatrician Barry?

    If neurology - go the Paediatric Neurologist rather than doubling up. Or at least in Australia - we refer back to the GP with a Neuro recommendation the wait can be up to 6 months for a paediatrician and then if they want a neuro it can be another 4-5 months. Cut the middle man and go straight to the right specialist.

    However, I am unsure how this works in other countries.
     
  13. RobinP

    RobinP Well-Known Member

    If barry is Uk then referral direct to paediatric neurologist is unlikely uless you are part of that particular team, which may be the case for some childrens specialist hospitals.

    All hospitals have different waits for the paediatrician. I have more or less direct immediate (within 1 week) access where I am and at places I worked before but not everyone is as fortunate.

    Is the health system in Canada more privately based? If possible though, I would agree and go straight to the neurologist.

    Robin
     
  14. Canada Foot Guy

    Canada Foot Guy Active Member

    In Ontario, Canada the Family Physician (GP) is the quarterback - for any specialist you need a referral from the GP....in some cases if you are willing to pay directly not using our provincial health care you may go direct but this is rarely done...
     
  15. Bug

    Bug Well-Known Member

    Same system here, GP's are the gatekeepers and you really want them on yours and the child's side.

    The GP can refer to either the paed or the neuro or whoever. Glad to hear this is similar and that you don't need the paed to get to the paed neuro....what a complex path.

    How did you go?
     
  16. Canada Foot Guy

    Canada Foot Guy Active Member

    Still pending toddler coming back in next month
     
  17. BAMBLE1976

    BAMBLE1976 Active Member

    Hi

    I am in the north east of england and the referral has to go through the paediatrician onto the paed neurologist unfortunately!!! Slow cogs!

    Barry
     
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