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This morning I examined a six-month-old girl with extremely restricted range of motion in right ankle joint – approximately 5-10 degrees. The foot is held in a neutral mid-stance position. Radiographic examination reveals no bony abnormality or malformation. Forced extension or flexion causes obvious distress. Birth was unremarkable except that the baby was in a breached position until two weeks prior to delivery then she righted herself. Normal delivery – no forceps or suction. The left ankle ROM is as one would expect in a six-month-old baby – more than adequate. No adverse family history. No neurological symptoms. No sensory loss.
My thoughts were that she may have had the ankle extended for a protracted period – perhaps against the womb wall – during pregnancy and this has caused contracture of the anterior muscle compartment and associated soft tissues. Is this feasible given six months have elapsed? Also, is there any other investigations/treatment that can be offered aside from gradual manipulation?
Hi Mark (others).
I would suggest that interuterine pressure may have caused soft tissue contracture/mal-development in this limb. In an infant this young my personal preference would be gentle manipulation/stretching, and due regard to other developmental milestones
Specific neurological tests should not be considered unless a) the limb does not begin to respond over a given period (say 3 months), or b) other developmental milestones give cause for concern.
Regards,
David
Several good quality replies were given there, so I am doing a cut and paste of them:
Quote:
Hi,
Have you considered taping / night splints with paediatric physio input.
Regards
John Bickerstaffe
Quote:
I assume that your child has a restriction of ankle joint plantarflexion? Does she also have a restriction of dorsiflexion? Is there any erythema, edema or history of trauma? Any other medical problems? Any history of infection or recent fevers? Are the subtalar, midtarsal or MPJs restricted on this foot also?
If all the above are normal, then why not start on having the parent do 5 minutes of dorsiflexion/plantarflexion manipulations of the ankle with every diaper change for the next two weeks to see how it affects the range of motion. Make exact notes of ankle range of motion available (i.e. from 5 degrees dorsiflexion to 10 degrees plantarflexion) at each office visit and see them every two weeks. I would bet that within three months of manipulations that the ankle joint ranges of motion will be nearly symmetrical and nonpainful.
Cheers,
Kevin
************************************************** **************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
Voice: (916) 925-8111 Fax: (916) 925-8136
************************************************** **************************
Quote:
Sorry, I thought I had made that clear. Yes DF and PF are restricted
perhaps only about 10 degrees from the fixed position. Other joint ROM
appear normal although it's difficult to be exact with ST movement in a six-
year-old with a rigid ankle joint. No problems with mid-tarsal or forefoot
joint ROM.
Otherwise she is a lovely healthy girl with no history of trauma or
infection. No oedema, inflamation or other symptoms whatsoever. Whilst I
agree that manipulation by mum is probably the best way forward, I was
hoping to find out what the primary aetiology was. Any ideas?
Thanks for your interest.
Mark
Quote:
My approach in these types of cases is try the simple treatment first to see how they respond. If she responds successfully to manipulation, then no further diagnostic tests are required, unless the parent insists on them. If, however, the girl does not respond to manipulation, then I would do more tests. Sometimes the treatment gives you a better diagnosis than any diagnostic tests will for a six month old (I assume this child is six months old even though your last posting said it was a six year old girl.)
Cheers,
Kevin
Quote:
Thanks Kevin. Often the simple approach works best - I'll let you know how
we get on. Yes and of course you are right - it should have read six-month-
old.
Best wishes
Mark Russell
Quote:
Mark,
Was the problem present at birth, calcaneo-valgus???
However, this is usually a flexible deformity and normally resolves without intervention or manipulation as Kevin suggested.
regards
Tony Achilles
Quote:
Hi Tony
According to mother the ankle has always been rigid - not certain about
calcaneo-valgus though, the rearfoot realtionship appears normal enough to
me. What she did comment was that the 'leg took a while to come down',
which I took to meen the hip was flexed and possibly was subject to
restricted ROM also for a while. This has now resolved by the ankle
problem remains.
I agreee that gradual manipulation is probably the way forward but remain
curious as to the aetiology. Is this condition common and if so does intra-
uterine position contribute to other developmental anomalies?
Mark Russell
Quote:
Mark, Tony and Colleagues:
Infants born with calcaneal valgus will often have their dorsal foot contacting the anterior tibia when they are first born. This condition will produce a lack of ankle joint plantarflexion if not manipulated early on. These children often have a characteristic concavity over the sinus tarsi when the foot is plantarflexed and inverted but have relatively normal STJ range of motion. Lack of STJ range of motion would indicate possible congenital convex pes valgus (this is relatively rare) and this condition should have been caught at birth since the STJ basically doesn't move.
Sounds to me like this child may have an untreated calcaneal valgus that should respond to manipulation.
Cheers,
Kevin
************************************************** **************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My first thought when I read it was that the infant has a calcanevalgus
which Tony Achilles has already suggested. This is consistent with the
dorsiflexed position of the foot described. However, these feet usually
have quite a bit of range of motion in the direction of dorsiflexion
which does not seem to be the case here. That makes me suspicious of a
vertical or oblique talus which present more often with reduced
dorsiflexion and plantarflexion. Here, however, overall subtalar and
midtarsal motion would be reduced as well. If as you said in the
original post that radiographs were normal this would also argue against
out vertical talus which would exhibit a dislocated talo-navicular joint
with severe plantarflexion of the talus and the neck of the talus
articulating with the cartilaginous anlog of the navicular. That leads
me to the likelihood of either severe calcaneovalgus or obligue talus
syndrome which is a variant with severe obliquity of the talus in the
sagittal plane making it more like vertical talus but without the
dislocated T-N joint. I would take another look at that lateral x-ray
and assess the T-N joint more carefully. I would also make sure there
are no neurological problems if vertical talus is a possibility.
If oblique talus or severe calcanevalgus is the diagnosis, then attempts
to improve the sagittal plane position and range of motion of the ankle
with manipulations, tapings or plaster cast applications are my
management suggestions.
You ask, too, if positional etiologies stemming from intra-uterine
pressure are possible presenting at 6 months out from delivery. I say,
indeed, as all too many conditions present to us at older ages than they
should because no one notices, no one refers, or parents just wait until
gait and the onset of bigger problems. There, I feel better...
Regards,
Russ
Russell G. Volpe, DPM
Professor
Department of Pediatrics and Orthopedics
New York College of Podiatric Medicine
Foot Clinics of New York
1800 Park Avenue
New York, New York 10035
phone 212 410-8129
fax 212-410-8440
Thanks very much for the opinion - it’s much appreciated. Somehow I knew I
was going to have to dust off the old textbooks for this one. A couple of
additional points if I may.
With regard to the position of the foot. It is neither plantar grade or
dorsiflexed – it is what I would term as a neutral mid-stance position i.e.
at right angles with the lower leg. Passive movement allows slightly
greater dorsiflexion than plantarflexion – but only slightly. There is
severe resistance after the few degrees of movement is reached. In essence
the ankle joint feels ‘locked’. If it is soft tissue contracture then it is
not demonstrating a great deal of elasticity.
I think I’ll have a look at the radiograph plates – I have only been given
the report so far – and look again at the T-N relationship before I proceed
further. I have to say I can see no rearfoot abnormality to the extent of a
severe calcaneovalgus but my experience with this age of infant is fairly
limited.
One last point. The mother made remark that it took some time for the ‘leg
to come down’ and I thought initially there may have been some restriction
at the hip joint. But what if there was some pathology at the knee- such as
subluxed superior tib-fib joint? Is there not a relationship between this
and calcaneovalgus in adults? If there was discomfort here the natural
position would be to flex the knee and keep the leg raised. Shoot me down
if I’m wide of the mark.
>With regard to the position of the foot. It is neither plantar grade or dorsiflexed - it is what I would term as a neutral mid-stance position i.e. at right angles with the lower leg. Passive movement allows slightly greater dorsiflexion than plantarflexion - but only slightly. There is severe resistance after the few degrees of movement is reached. In essence the ankle joint feels 'locked'. If it is soft tissue contracture then it is not demonstrating a great deal of elasticity.<
Are you certain that the limited sagittal plane motion that you can observe clinically is actually occurring at the ankle joint, or is it possible that the ankle might be immobile and that the sagittal plane motion you can observe (foot to leg) might actually be occurring distally at the subtalar and/or midtarsal joints? Any difference in ROM with the knee extended and flexed? If you feel like the ankle is "locked", you might want to trust your instincts and look at the ankle more closely. Perhaps an ultrasound might help determine if there is any ankle joint motion or not. Out of curiosity, when you move the STJ, what is the approximate frontal plane ROM of the calcaneus (ie. roughly how much calcaneal inversion/eversion motion can you observe)?
Respectfully,
Jeff Root
Quote:
Jeff
No, I cannot be certain having only examined the child once. I will need to bring her in again over the next few days to establish whether it is indeed ankle motion or as you suggest ST or mid-tarsal movement. Likewise with calcaneal inversion/eversion. Clinically it is difficult to establish accurately what the ROM at particular joints actually is in an infant of this age where development of the osseous centres are still in their early stages, but my initial impression was that there was some movement at the ankle joint although it was severely retarded and beyond that, fixed. I will report back when I have carried out a more thorough examination.
I have now had a chance to examine baby Emma once more. Jeff your intuition
was spot on. There is no ankle movement and what I thought was ankle ROM
was in fact mid-tarsal motion. Further I cannot manage to elicit any
calcaneal inversion or eversion whatsoever. What I also missed during the
intial examination was that there does not appear to be a medial malleolus -
although I can palpate the distal end of the tibia. Compared to the left
ankle the malleolus is absent. I have now obtained the original
radiographic plates but they have been forwarded to me on CD-ROM and
unfortunately my machine cannot read them. I've tried to attach them here but the file size is too large. Craig has kindly offered to link them to the site via a web page and hopefully you'll be able to view shortly. I look forward to your comments.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
If I'm viewing these correctly, it appears to me that the navicular is
abducted (subluxed/dislocated?) laterally and is superimposed over the
lateral column (cuboid). Correct? Is the talus anteriorly subluxed? On
X-ray number one it almost appears like the talus is out of the ankle
mortis. Russ, what do you make of this? You certainly have an extensive
background in pediatrics. Anyone else have any thoughts on this? Also,
what further diagnostics or treatment would you recommend at this point?
Craig and Mark, thanks for posting the X-rays.
Seeing the x-rays for the first time, I would suspect congenital convex pes valgus. You should order an MRI scan to see the position of the cartilaginous anlage of the navicular relative to the talus. In addition, I would then suggest immediate referral to a surgical specialist who specializes in pediatric foot pathology.
I'm most grateful for the opinion. This morning was the first opportunity I
have had to look at these images and I agree with Jeff insomuch as the
talus appears anteriorally displaced and does not appear to have congruity
within the ankle mortice. I am not so sure about CCPV though. Would there
not be an obvious abnormality with the rearfoot/forefoot relationship if
pes valgus was present? I'm aware that the abundance of infant adipose
tissue can mask a great deal but the foot does appear 'normal' to me. It's
just that the ankle is fixed. If it would help I'll try and arrange some
digital photographs early next week so you can see for yourself? In the
meantime I take it you would agree that we do not initiate any manipulation
until we establish the exact pathology?
Kind regards
Mark Russell
Last edited by Admin : 12th November 2004 at 02:33 AM.
Having thought a little more and having revisited these images again I am
left with the feeling that this is not CCPV or VT. With CCPV the heel is
usually elevated and the calcaneum lies in equinus and valgus. The forefoot
is normally fixed in eversion and the plantar aspect of the foot is convex
(with the head of the talus forming the lowest point on the medial arch).
That is not the clinical picture here. From the lateral image I cannot see how the talus can be described as vertical. Also I am concerned about the distal
end of the tibia. Can you look at this again and bear in mind my comment
about the medial malleolus? If it were a congenital malformation of the tibia - possibly due to a positional intra-uterine abnormality - wouldn't this displace the talusanteriorally in the way the image shows? Just a thought.
Thanks once again for your time.
Mark Russell
Last edited by Mark Russell : 12th November 2004 at 06:42 AM.
Russ Volpe is much more of an expert on these feet than I am. However, if the navicular is sitting on top of the talar neck, instead of anterior to the talar head as it should be, this would plantarflex the talus so that ankle range of motion would be severely restricted. MRI and referral would be my choices from what I know of this patient.
Cheers,
Kevin
************************************************** **************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
If I can bring you up-to-date on the progress of the baby girl with the
fixed ankle abnormality.
I referred this child to a consultant orthopaedic surgeon at a leading
children's hospital in the UK two weeks ago and forwarded the x-rays and
clinical findings. The opinion received runs;
"......she is a second child born at full-term by normal delivery. No
family history. She was born with her right hip flexed up and against the
chest but with no apparent knee of foot deformities. It took approx. three
months for the hip to come down. It was then noted that the foot did not
move normally. Clinically she now has full hip and knee movements both
sides. the right foot has a normal shape, but a jog only of
dorsiflexion/plantar flexion about neutral. Normal forefoot/hindfoot
alignment and moves toes normally on sroking sole of foot. There is no
evidence of thigh, calf or foot wasting. Normal body landmarks. Spine
normal.
....x-rays from six weeks ago appear to show normal bony elements to the
right foot in normal alignment.
She presents with an isolated foot contracture, possibly due to lack of
foetal movement and this would be a very minor form of arthrogryposis.
There is no evidence of any neurological abnormality or syndrome. In the
first instance she would benefit from simple passive mobilisation and this
can be supplemented by active movements when she starts standing and
walking. With the foot in a normal alignment there is no indication for
corrective surgery at this stage......."
I am very grateful for this opinion, as I have been with all those who
submitted replies on this forum in recent weeks. However, I still have
concerns at the diagnosis and proposed management, even though I greatly
respect the views and experience from those kind enough to offer them. If
this is simply a soft tissue contracture, I would have expected some degree
of movement due the elastic nature of these structures and also because the
foot, even if it had been fixed in some intra-uterine position, has now
been in 'neutral, for nearly nine months now, since she was born. There
also seems to be a difference of opinion regarding the interpretation of
the x-rays.
I don't wish to contradict any of the contributors, or indeed this surgeon,
but my gut instinct is to proceed with caution, especially where passive
mobilisation is concerned. The child’s health visitor referred her because the paediatric physiotherapist could not elicit any movement during
earlier mobilisation sessions, and on that basis I am reluctant to advise
any recommencement of physiotherapy until I have an accurate diagnosis.
Am I being too cautious?
Mark Russell
Last edited by Mark Russell : 2nd December 2004 at 09:36 AM.
Ankle ROM in six-month-old girl - advice required.
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