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Progressive met adductus in 9 year old

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  #1  
Old 16th November 2014, 11:21 PM
poya17 poya17 is offline
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Default Progressive met adductus in 9 year old

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Would appreciate some advice/input on my 9 year old patient. I do not normally see such severe cases like this and would refer on but there are no podopaedatric specialists in Singapore. Parents brought her in last year after having noted that the left foot 'had gone out of shape over the last year'. They had previously seen an orthopaedic surgeon who recommended leaving it alone until she was fully grown after which she would need surgery. The child complained of anterior ankle pain after activity and frequent falls. She had also had lateral ankle sprains.

She was a 'C' section birth and all milestones were normal. Her mother has a mild met adductus and her sister had a similar foot shape on the right foot but not nearly as severe.

She has general ligamentous laxity. Left foot rear foot was inverted in relaxed and neutral calcaneal stance, inverted and adducted forefoot, hyper mobile ankle and subtler joint, tight peroneals, genu recurvatum, no response to Jacks test and medial fat pad displacement at the heel.

I recommended physio and massage for the peroneals and I referred her to a paediatric orthopod and a neurologist. The Drs noted a slightly increased knee reflex on the left side and suggested a MRI of the brain. Parents were not keen to go ahead with this.

After consultation with some colleagues in UK and Australia for the left foot I gave her a 3mm poly orthotic with reduced arch fill, 0 dgr intrinsic grind, apertured heel cup, 6 dgr valgus EVA forefoot wedge extended to the sulcus. The orthotics have reduced all the pain and there have been no further ankle sprains and activity wise there are no problems.

When she came in for her review the foot has definitely progressed. I noted that she now has a habit of standing with one arm straight and the other arm hooked behind her back and round the straight arm (hope this makes sense!) which appears to be causing rotation at the pelvis and therefore causing the foot to rotate further. I have advised to stop this and again see physio to reduce the pelvic rotation.

What I would like advice on is there anything further I can add to the orthotic? The parents also asked me if a night splint of some form would help? The met adducts is reducible to some degree but not fully.

Thanks in advance.
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  #2  
Old 17th November 2014, 06:04 AM
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Default Re: Progressive met adductus in 9 year old

Convince them to have the MRI. Reflex changes and progressive deformities are serious. Don't placate the parents with an orthotic when you don't know what you are treating.
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Old 17th November 2014, 06:24 AM
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Default Re: Progressive met adductus in 9 year old

I will speak to them again but they were pretty certain they didn't want to have it/put her through it and the neurologist hasn't pushed them to do it. If they are not willing to do it I would still like to try and do more for the patient if it's possible. Also I think a fair part of the foot worsening is coming from the pelvic rotation so maybe I should wait until that is sorted out by the physio before pressurising them into doing something they are not happy about.
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Old 18th November 2014, 04:37 AM
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Default Re: Progressive met adductus in 9 year old

I agree Neurologist!
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Old 18th November 2014, 05:26 AM
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Default Re: Progressive met adductus in 9 year old

Neurologist been seen already though and not pushing for the MRI!
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Old 18th November 2014, 11:49 AM
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Default Re: Progressive met adductus in 9 year old

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Originally Posted by poya17 View Post
Would appreciate some advice/input on my 9 year old patient. I do not normally see such severe cases like this and would refer on but there are no podopaedatric specialists in Singapore. Parents brought her in last year after having noted that the left foot 'had gone out of shape over the last year'. They had previously seen an orthopaedic surgeon who recommended leaving it alone until she was fully grown after which she would need surgery. The child complained of anterior ankle pain after activity and frequent falls. She had also had lateral ankle sprains.

She was a 'C' section birth and all milestones were normal. Her mother has a mild met adductus and her sister had a similar foot shape on the right foot but not nearly as severe.

She has general ligamentous laxity. Left foot rear foot was inverted in relaxed and neutral calcaneal stance, inverted and adducted forefoot, hyper mobile ankle and subtler joint, tight peroneals, genu recurvatum, no response to Jacks test and medial fat pad displacement at the heel.

I recommended physio and massage for the peroneals and I referred her to a paediatric orthopod and a neurologist. The Drs noted a slightly increased knee reflex on the left side and suggested a MRI of the brain. Parents were not keen to go ahead with this.

After consultation with some colleagues in UK and Australia for the left foot I gave her a 3mm poly orthotic with reduced arch fill, 0 dgr intrinsic grind, apertured heel cup, 6 dgr valgus EVA forefoot wedge extended to the sulcus. The orthotics have reduced all the pain and there have been no further ankle sprains and activity wise there are no problems.

When she came in for her review the foot has definitely progressed. I noted that she now has a habit of standing with one arm straight and the other arm hooked behind her back and round the straight arm (hope this makes sense!) which appears to be causing rotation at the pelvis and therefore causing the foot to rotate further. I have advised to stop this and again see physio to reduce the pelvic rotation.

What I would like advice on is there anything further I can add to the orthotic? The parents also asked me if a night splint of some form would help? The met adducts is reducible to some degree but not fully.

Thanks in advance.
Poya17, what is your real name? You will get more responses to your request for help and clinical advice by providing your real name here on Podiatry Arena.

I would examine this patient closely for muscle strength in the peroneals and all the other muscles of the leg/foot bilaterally. Are the peroneals (the only pronators of the subtalar joint) weak? In addition, is there any indication of a supination spasm of the posterior tibial muscle? This may be caused by injury to the articulating surfaces of the talo-calcaneal joint and is fairly unusual. Does the child have full range of motion of the subtalar joint in non-weightbearing examination? Is there any catching or "ratcheting" during subtalar joint pronation which indicates possible supination spasm?

Also, stand the child up on a valgus wedge (i.e. Coleman block test) to see if the subtalar will pronate with an external pronation moment applied to the plantar foot. What happens? If the child doesn't pronate with a large valgus wedge, then no foot orthosis will help.

In addition, how does the child walk and run? Does she stumble or move inefficiently? This is very important.

If the neurologist has cleared the patient and suggested that an MRI is not necessary, then I would have no problem proceeding with the above tests to come up with my own provisional diagnosis. In addition, I have no problem with treating this patient with a well-constructed foot orthosis while the child is being worked up for the cause of the abnormal foot posture. If any muscle weakness/spasm is detected, then the child should be sent back to the neurologist for further examination and possible MRI, while still treating the patient with a foot orthosis or in-shoe padding (i.e. valgus wedging) depending on the results of your examination and testing.

Please keep us informed of the child's progress. It sounds like a very interesting case.

Hope this information allows you to better help your patient and her parents.
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Old 18th November 2014, 02:06 PM
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Default Re: Progressive met adductus in 9 year old

Sorry Poya missed that bit!
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Old 18th November 2014, 05:31 PM
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Default Re: Progressive met adductus in 9 year old

Related Threads:
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Metatarsus adductus: Development of a non-surgical treatment pathway.
Acquired metatarsus adductus
Assumptions of metatarsus adductus
Metatarsus Adductus Adult Case
Met Adductus in Adults
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Old 18th November 2014, 08:12 PM
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Default Re: Progressive met adductus in 9 year old

Progressive unilateral cavo-varus should send warning bells ringing, particularly CNS lesion such as spinal cord tumour.

The worst that can happen is that there is no pathology found. The best is you save their life or prevent paralysis. MRI of spine +/- brain is essential IMHO.

Speaking from experience of a similar case...

LL
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Old 19th November 2014, 06:02 AM
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Default Re: Progressive met adductus in 9 year old

Thanks for this advice Kevin. The sub-talar joint was hyper mobile on non-weightbearing assessment. At the first assessment there was some catching on movement at the STJ and I asked them to mention this to the consultants. It was just after a recent ankle sprain so I asked them to come back for reassessment a few weeks later after which I haven't been able to replicate it so I put it down to the sprain. I don't remember noting any significant muscle imbalance but I will get the physio to re-assess as they will be seeing soon, and I'll also get her to try the Coleman block. I will also talk to the parents about the feedback about the MRI and see if they want to reconsider. The Mother in particular is worried about having her sedated for it.

Thanks again Helen
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Old 19th November 2014, 06:04 AM
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Default Re: Progressive met adductus in 9 year old

I forgot to add that she has no problems activity wise. She plays tennis and does gymnastics.
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Old 19th November 2014, 02:23 PM
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Default Re: Progressive met adductus in 9 year old

Quote:
Originally Posted by poya17 View Post
Thanks for this advice Kevin. The sub-talar joint was hyper mobile on non-weightbearing assessment. At the first assessment there was some catching on movement at the STJ and I asked them to mention this to the consultants. It was just after a recent ankle sprain so I asked them to come back for reassessment a few weeks later after which I haven't been able to replicate it so I put it down to the sprain. I don't remember noting any significant muscle imbalance but I will get the physio to re-assess as they will be seeing soon, and I'll also get her to try the Coleman block. I will also talk to the parents about the feedback about the MRI and see if they want to reconsider. The Mother in particular is worried about having her sedated for it.

Thanks again Helen
Why can't you do muscle testing and do the Coleman Block Test (or alternatively the Maximum Pronation Test) on this patient yourself? These are easy tests to perform that every podiatrist should know how to do.

It is good news that she is normally active without issues and it is possible this is just a biomechanical problem that can be addressed with custom foot orthoses. However, you must also realize that if the foot is becoming more supinated over time, this could also indicate an occult pathology within the central or peripheral nervous system that may require further work-up, including MRI, nerve conduction velocity (NCV) and electromyogram (EMG), to elucidate. These neurological pathologies are better to diagnose early, rather than later.

In the mean time, you should be treating her with a custom foot orthosis and/or modified over-the-counter foot orthosis with lateral-valgus padding from the heel to the toe sulcus. This, by itself, may improve the posture of the foot over time and certainly, the response to this therapy, will give you added knowledge as to what pathologies you are, and aren't, dealing with in this young patient.

It would probably help if you read this chapter before you proceed any further.

http://books.google.com/books?id=gE6...ildren&f=false

This article would also be helpful for you to read:

Quote:
Cavus foot deformity in children.

Schwend RM, Drennan JC

J Am Acad Orthop Surg. 2003 May-Jun;11(3):201-11.

Abstract

A cavus deformity of the foot is easily recognizable, but appropriate neurologic assessment can help to determine the etiology. Cavovarus, the most frequent type of cavus foot, presents with an elevated medial longitudinal arch, first ray plantarflexion, and, if rigid, a fixed heel varus. Common causes include progressive motor sensory conditions, typically Charcot-Marie-Tooth disease, and nonprogressive conditions such as cerebral palsy and poliomyelitis. A calcaneocavus foot may be seen in poliomyelitis, spinal dysraphism, and peripheral neuropathy. Initially, the cavus deformity is flexible, but if left untreated, it becomes a fixed bony deformity. Physical examination should include the cavovarus block test, which assesses flexibility of the hindfoot deformity and can direct surgical treatment. Standing radiographs of the feet and spine, magnetic resonance imaging, and electrodiagnostic studies may be useful. Management goals are to obtain a plantigrade, mobile, pain-free, stable, motor-balanced foot. Surgical options include soft-tissue and plantar fascia releases for a flexible deformity, osteotomy for a fixed deformity, and tendon transfers to restore muscle balance. Triple arthrodesis has poor long-term results in patients with progressive deformity and sensory impairment.
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Old 19th November 2014, 05:24 PM
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Default Re: Progressive met adductus in 9 year old

The Physio is seeing her this week. Just wanted to get it done sooner rather than later. I will also check when I review her the week after.
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Old 19th December 2014, 07:36 AM
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Default Re: Progressive met adductus in 9 year old

Quick update on this patient for those of you who were kind enough to respond. We asked the parents to dig out some baby photos and it appears the deformity has in fact been there since birth and gone un-noticed until a year or so ago! On re-testing the muscles I could find no weakness except in the gatrocs and soleus. Coleman block straightened up the foot considerably so I have increased the lateral wedging on her insole. I am now waiting on them seeing a new neurologist in January for a second opinion regarding the MRI as the foot deformity has a definitely progressed. They have seen a paediatric orthopaedic surgeon who has recommended cutting out the planter fascia as it is 'a bit like the appendix and doesn't do anything'. I questioned this further asking if it was a release but the mother insisted that he said he would remove the planter fascia and cast her for three to four weeks. I've never heard of anyone doing this before?
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Old 19th December 2014, 10:53 AM
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Default Re: Progressive met adductus in 9 year old

Quote:
Originally Posted by poya17 View Post
Quick update on this patient for those of you who were kind enough to respond. We asked the parents to dig out some baby photos and it appears the deformity has in fact been there since birth and gone un-noticed until a year or so ago! On re-testing the muscles I could find no weakness except in the gatrocs and soleus. Coleman block straightened up the foot considerably so I have increased the lateral wedging on her insole. I am now waiting on them seeing a new neurologist in January for a second opinion regarding the MRI as the foot deformity has a definitely progressed. They have seen a paediatric orthopaedic surgeon who has recommended cutting out the planter fascia as it is 'a bit like the appendix and doesn't do anything'. I questioned this further asking if it was a release but the mother insisted that he said he would remove the planter fascia and cast her for three to four weeks. I've never heard of anyone doing this before?
Sounds like it's time for a consult with someone who knows more about foot function.
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