Intoeing 12 year old

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Hi,
I've just been reading previous posts regarding intoeing and there is a wealth of information, discussion and debate regarding infants and toddlers regarding intoeing. My question is the dilemma of when you get parents bringing 12 year olds in with significant intoeing who have obviously missed their window of opportunity 7,8,9 0r 10 years before.

What can be done or advised? My thoughts with this are that it may be too late for anything constructive to be done. Research is certainly limited and the literature sparse. Footwear?, orthotics?
Obviously there are different reasons for intoeing.
Does anyone have anything constructive anecdotally?


Thanks,

Brendan

 

my first question will be what sort of symptoms does your patient have
what level of intoeing is it at, eg metatarsus adductus/ internal tibial torsion or internal femoral torsion.....dont forget your versions as you go along.

now for most of the patients that i see in my clinic, they tend to be referrals from physiotherapy with symptomatic patellofemoral dysfunction that is also idiopathic/ trauma induced. the x-rays are unremarkable in most cases, however some findings have been tight hamstrings and some underdevelopment of the vastus medialis........my anecdotal assumption will be discongruency resulting in tissue irritation that is then interpreted as pain.

if accomapnied with substantial functional pes plano valgus i will use a vecto orthotic with/ without a first ray cut depending on the plantarflection of the first ray, just to lock the MTJ AND A 6degrees medial posting that i will gradually take down to 2 as proceed with treatment.

this will not change the anatomical variation of normal development but to help ease the symptomology, only if its present, otherwise they can always grow up into adults who intoes.

hope this little offering will suffice

thanks for your post

 

Hi podtiger
I get quite a lot of 'mature' in toers - it seems to hit a lot of teenagers during their growth spurts - from experience and working alongside physios it seems that hip rotation,poor glut control and poor core stability seem to be the main contributers to this problem. We start them on exercises to work the gluts etc and then review them in six weeks - do not rush into orthtoics as this can often do the trick. If you palce them into stj neutral on wb and there is still rotation at the knee and femur then the problem is further up and not the feet at all!!
hope this helps
claire

 

Claire:

Please explain the mechanism by which working on gluteal strength and "core stability" in a patient with a structural abnormalities of internal tibial torsion and/or internal femoral torsion and/or metatarsus adductus will correct these problems for the patient. You may want to ask the physios you work with this same question.

 

Hi Kevin

obviously with met adductus working your gluts will not make any difference. We found that we had a large number of girls in - around puberty - that suddenly developed intoeing problems and that by addressing their mechanics from both physiotherapy and podiatyr angles they seemd to improve. The weak gluts seemed to contriubute greatly to a marked increase of inernal rotation of the femur in gait - by strengthening the gluts we have managed to achieve a good result. what would you suggest?

 

Claire:

The above posting sounds more reasonable to me than your initial posting. Now I understand you better.

If the femur is internally rotated during gait, then if we can increase the femoral external rotation moment in any fashion, then we should be able to externally rotate the femur to decrease an intoed position of our patient. External femoral rotataion moments may come from two sources: 1) distal sources, whereby we can increase the external rotation moment on the femur by increasing the subtalar joint supination moment by shoes, orthoses or muscle activity (e.g. posterior tibial muscle), or 2) proximal sources, whereby we can increase external femoral rotation moment by increasing contractile activity and strength of the external rotators of the hip (e.g. gluteals).

In the case of intoeing, it would be more desirable to use proximal sources of external femoral rotation moment (i.e. gluteal strengthening), than distal sources, since using proximal sources would tend to externally rotate the foot into a less internally rotated angle of gait whereas distal sources would tend to make the foot become more supinated and, thus, create a more internally rotated angle of gait.

Obtaining a better understanding of difficult clinical situations such as intoed gait patterns using the above type of mechanical analysis is an important step for clinicians who are striving toward arriving at the best approach for treatment of these types of complicated conditions.

 

get 'em ice skating.

For those that haven't noticed: height for height females have a wider pelvis than males, during puberty is when the female pelvis widens. Despite their wider pelvis, females have a narrower base of gait than a similar height male. Hence, the gluteals will tend to be "held" and function in a lengthened position; in response the gluteals add sarcomeres in series, resulting in long, weak gluteals- according to Janda anyway.

Hence: the reason "your bum looks big in this" is that you're female.

 

Thanks Kevin
you explain things much more eloquently than me ( be gentle with me I am new to this blogging thing) - simon I will have you know I am very proud of my African style arse - if it's good enough for JLo!!!

 

No worries- is that a picture of Pootle?

 

yes well done but you're showing your age - 30plus only would get that one! each time I see your picture I keep singing the flight of the bumble bee in my head now can't stop thanks very much

 

"Time is elastic and passions are plastic" Pop Will Eat Itself- inject me

But, The Flumps cannot be beaten.

And just listen to what you've put back in my head:
http://www.youtube.com/watch?v=T1mMQtk3IUE

 

ahhh that takes me back, quality times when salt and vinegar crisps burnt your mouth and they still gave you a mini bottle of milk and then had a nap in the afternoon at school - the milk has gone but sometimes when you get a DNA the nap remains - sorry podtiger we seem to have gone off track a bit!

 

Thank you one and all.
I really appreciated the discussion here. It makes you value the time you put into quality patient assessment and accurate history. Kevin's point about distal and proximal treatments were certainly noted.
It brings the physics of the human biomechanics into account.Which should be the basis of most our treatments

Thanks!!

 

After a gluteal strengthening program is undertaken how long do you normally find it takes to see a reduction in amount of in-toeing?

cheers,

josh

 

Hi Josh
we generally review the patients after six weeks, by this time (if they've been doing their exercises) you can see an improvement but this is a long term strategy and the patients need to know this - as Simon said it is worth suggesting exercise such as ice skating that they will continue to do and enjoy

 

dear colleagues

first and foremost i am going to admit that i have taken on board the suttle way of dealing with in-toeing from a proximal and distal aspect (i only did the distal approach and left the physios to deal with the proximal aspect and besides most of their referrals were as a result of failure on their part to resolve the problems proximally and i also have anecdotal proof of the benefits of my distal aspect approach.

maybe we need to grade the level or stages of intoeing and their corresponding symptoms, as i am not so sure with conviction that we are going to derotate a torsional abnormality irrespective of the amount of proximal and distal aspect involvement.......i dont want to sound as a prophet of doom here but i share the same sentiments with Josh.

guys rally with me on this one so that i can believe we can acheive this. so far i have re-refered all of my intoeing patients for specific external hip rotators strengthening and having to do some distal working on it from my side and hopefully i will get and give out positive results......my fears are i will be a dead cow or a victor



whose foot is it anyway

 

Hi Mr Nake.
Could you please explain the vecto orthotic. I may know this by another name.
This was from a previous post you did to this thread
'if accomanied with substantial functional pes plano valgus i will use a vecto orthotic with/ without a first ray cut depending on the plantarflection of the first ray, just to lock the MTJ AND A 6degrees medial posting that i will gradually take down to 2 as proceed with treatment.'
Thanks again for your help with this.

 

Kevin: In regard to your reasoning for proximal correction of in-toeing being more beneficial than distal correction...does this mean that one should always attempt to treat/manage this condition in a "proximal manner"before moving along to an orthtotic prescription?

Also, in regards to distal (orthotic) correction of in-toe gait: i am yet to have any real clinical experience in this area, so what do people like to prescribe? obviously there is the option of a medial flange however this would seemingly cause irritation in a lot of patients. what about a gait plate? or is this indicated in people that have an adducted gait?

Simon

 

dear pod tiger

A vector orthotic is a pre-formed orthotic that is used widely in the UK, to increase the external rotation moment on the tibia/fubula/femur (kirby), by increasing the STJ supination moment, hence helping with correction of some of the symptoms of intoeing especially PFD.

It does this by medial posts of varying degrees from 2-6 and it also allows for 1st ray cut outs for plantar flexed 1st rays as well as forefoot varus /valgus posts.

you can get it from this website: www.healthystep.co.uk:cool:


WHOSE FOOT IS IT ANYWAY?

 

Simon:

Anytime intoeing is being treated, the clinician should think both proximally and distally. In other words, the clinician should be thinking: what can I do for the patient proximally with their musculoskeletal system and what can I do distally with their musculoskeletal system and foot orthoses/shoes?

For intoeing, proximally, strengthening the external hip rotators and stretching the ligaments/tendons that limit external hip range of motion will usually be somewhat helpful. Distally, using a forefoot valgus wedged orthosis or gait plate may help, but I would not use any of those orthoses if pronation-related pathologies are expected from using these types of orthoses.

One must always remember, that asymptomatic intoeing in a child should not be treated so as to cause new symptoms from the treatment. A wise and balanced approach to treatment is necessary to prevent harm to the intoeing child and these cases should never be treated with the goal of simply giving the child a normal angle of gait, at the expense of increased pain or decreased activity levels.

 

Kevin: Your reasoning and explanation makes good sense to me. Thanks!

 

Hi Kevin
forefoot Valgus combined with rear-foot varus post and tolerated arch height will address pronation ,wouldnt it?