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Hi guys,
Sorry re my lack of posts. Would love some advice for this.

I have a patient , 17 month old boy, who has significant out toeing of both feet when he stands(about 50-80 degrees in both feet.) he does not walk yet but is able to walk a little while holding on to furniture. 5 or 6 steps then he stops.

On examination he has signicantly more hip external rotation with hips extended and flexed(Up to 80 degrees) with significantly less internal rotation.
I am fairly sure that tibial external torsion is not a problem. However while he is standing in such an out toed position it places pressure on his feet which may contribute to forefoot abduction and perhaps tibial torsion.

His feet stand in a very pronated position which is not helped by the abducted position of his legs.

Developmentally: late crawler(13 months); saying a few words at moment; reasonably good hand eye coordination; happy disposition; in 90th percentile for height and weight; doesn't seem keen to walk, happy to crawl; now has fairly good upper and lower body strength. No problems with birth or post natally.
Nerological: Plantar flexed first rays; flexes toes when rubbing finger along plantar surface; normal Achilles tendon and knee reflexes.

I haven't really suggested anything yet. Using this period as a window period as a prewalker really. I would say hip exercises would be warranted but I am stuck after this?
Does anyone out there have any thoughts?

Possibly Calcaneovalgus?
Peroneal tightness and Gastroc equinus but otherwise low tone? When cruising the furniture does he keep his knees extended?
I would recommend an assessment by a paediatric physio if possible if so.

Good luck!

Thanks for the reply. He does keep his knees extended when trying to walk.
Calcaneovalgus did cross my mind. Unsure about peroneal tightness but there is fair amount of ankle flexibility in sagittal plane. Generally very flexible lower limbs and foot joints.
Was considering a paed physio as well as I am feeling a bit perplexed by this.
Thanks again.

I agree with hmccausl and the referral to a pead physio for assessment or a pod that may see more kids? Calc valgus is a possibility as is general low tone etc.

Don't forget shoes with a good heel counter can be used as the first and sometimes the most appropriate orthotic while playing the waiting game and getting second opinions.

__________________
Cheers,
Cylie.... in a permanent state of confusion

Thanks

Hello,

He is still young enough not to panic but you don't want to miss something critical either.

Do you think this child is in pain? It can be hard to tell if he isn't talking much but do you think he is uncomfortable when he takes a few steps? Will he move towards toys/food/parents or avoid moving alltogether?

Also, what are the parents like? Abducted? Late walkers? Family history? He may be an average member of the family.

What do you think about ordering some X-rays, just to rule some major things out? It could give you a diagnosis or otherwise reassure you and the parents that he is normal for his age.

Sorry about all the questions! I'm just trying to get the full picture

Good Luck

Hi all,

this case sound very similar to a littel girl I saw about a year ago. She was 18 months old and developmentally had reached all of her milestones except she wasn't walking. A health visitor referred her to me because she thought her excessively pronated feet were the problem.
I have to say I immediately thought calcaneovalgus.
I took some pics and e-mailed a paeds physio and a consultant paediatrician for advice and then referred her on for assessment.
They initially checked for hip dysplasia but all was normal.
To cut a long story short some 9 months later this little girl has now been given a probable diagnosis of CP (unknown origin).
I've been helping out with her care in terms of orthoses - they have tried her in AFOs but she doesn't tolerate them very well so I've made her some devices with a high medial edge and deep heel cups. This appears to be at least providing some supinatory moments to counter her excessive pronation.
Not the easiest feet I've ever cast but ceratinly the smallest!!
When last I saw her (about a month ago), she hadn't yet take her first independent steps but was cruising around furniture a lot more freely (she could just pull her self up and stand when I first saw her), and she was attempting to walk with her mum holding her hand.
Progress is slow but sure!!

I'm not trying to imply that this may be the case for your boy but sometimes you can get a feel that this isn't like other children you have treated of a similar age and if you are suspecting something best to have it checked out.

Like the others I would suggest if you can access a paeds physio you should try and get an assessment with them (preferably a joint assessment) and if you are able to perhaps make a referral to a paediatrician.

good luck
Michael

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Michael Gates,
Podiatrist,
Inverness ,
Highlands
Scotland

Hi,
Thanks for everyones help regarding this. Much appreciated. I'm not a big user of this site so I apologise for not getting back to you.
To give you all an update re this case I did a joint clinic with a paed physio who ruled out any neurological issues. I did suspect this but I wanted to make sure for my own piece of mind and the parents. This boy is able to stand up quite easily. He is also quite big for his age which would make it hard to find his legs.
His parents were late walkers but not that late. I've decided that he should progress to stiff soled shoes with higher medial and lateral uppers. I'm holding off on triplanar wedges for a few weeks but i think he will need some extra support there to help him along. I'm going to monitor his progress there. Already he seems more stable in his new shoes but he does find them cumbersome when climbing and playing.
Hope this fills everone in.

Thanks again!