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I amhoping that someone can help me with this please.

A 12 yo male who only plays basketball and does swimming once a week was noted by the shoe shop assistant as having a pronated Left foot. This had never been noted by either parent and the child had never complained of any leg/foot/ankle pain in the past. The mother, hence brought him for assessment.

Initially the child presented with:

Left foot very pronated in the non weightbearing position and on stance it was severe, with "too many toes"sign, total collapse of the mid foot, and abduction of the foot,HK formation on the plantar aspect of the L hallux IPJ.

The only history to mark was a green stick fracture of the left fibula at the age of 3y.

He also has sacral tilt, shoulder tilt and forward head projection, but no obvious leg length discrepancy to note visually. However, measuring the legs gives a distinct discrepancy...the RIGHT being longer than the affected side??!! Yes, we checked it twice.

I thought that this may be a Posterior tibial tendon dysfunction, but in one so young, male and without any trauma history, I am not so sure.

Can any one suggest a differential diagnoses, or anything else I need to test for or may have missed please?

thanks Kym

Kym

This may suggest there was a significant concurrent hidfoot eversion injury that could have ruptured the superfical and/or deep deltoid ligs +/- spring ligament -> leading to acquired flatfoot.

Otherwise, consider a STJ coalition.

LL

Kym:

I would tend to agree with Lucky LisFranc (what is your real name anyway, LL???!).

In the few children that I have seen with a fairly rapid increase in flatfoot over a short period of time, I have felt that one of the components of the spring ligament complex (Davis WH, Sobel M, DiCarlo EF, et al: Gross, histological, microvascular anatomy and biomechanical testing of the spring ligament complex. Foot Ankle Int. 17:95-102, 1996) had ruptured on them (unless they had developed a tarsal coalition and peroneal spasm). However, the big question is: has an isolated spring ligament complex rupture ever been reported or investigated in the literature in this age group? I imagine the only way to diagnose this conclusively would be to either do a MRI with a high resolution coil or do surgery to investigate/repair the area. Since I don't do surgery on these I would be interested in any others that may have had surgical experience with these lesions in children or know of any literature that describes this problem.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Hi Kym,

Has he been tested for any neurological involvment?

Thanks

Declan

Thanks Declan,

yes, the child has been checked out by a paediatric chiropractor, and there is lots of neuro stuff occurring with muscle weakness bilaterally.

Kym

I also agree with LL (what a cool name :) )

Just as an aside though - is he about to stand up on his toes - both fee, what happens to the calc postition? If he can, is he able to do it on the affected foot only bearing all his body weight?

dear Bug,
Thanks, have tried this and the child can bear weight on the affected foot whilst on tip toes and holding the other off the ground...the calc only inverts very marginally. have also tried testing for muscle strength with resistence to inversion and eversion, but there is little to no difference between the sides, and he can demonstate reasonable muscle strength. Any other suggestions?? Any suggestions about the best orthotic device to use in this unilateral sided problem? Thanks, kym

I think then you can fairly confidently rule out Post tib tendon dysfunction however if the calc is not everting you need to look back at Kevin's or LL's suggestions and look radiologically for spring ligament rupture or even start with an x-ray to rule out subtalar coalition (looking at the Syme line, halo sign etc being indicators that further radiological investigation is needed).

I noted you havn't mentioned if this as always been present or something that has and only recently become a problem with increased activity.

As far as treatment at the moment - I'd be looking just at accomodating where possible, I'd use a casted semi rigid device, and try and hold the subtalar joint as close to neutral as possible, also with sorbothene padding to reduce shear.

We have done the Xrays and there is no sub talar joint coalition noted. spring ligament rupture I believe is a little more complicated to diagnose and I'm fairly certain neither the mum or child will want surgery!!.....guess its just orthoses then!
Thanks, Kym

Kym,

X-rays will only show osseus coalition. He might well have a fibrous coalition, which will only be picked up on MRI

peter,

Thanks for the suggestion, I will follow this up with the mum and the GP in the new year when they are due back. Kym

Hi Kym,
Not sure if I've missed something already mentioned, but I was just curious about the mobility of the midtarsal, STJ and TC joint on the affected side (left) compared to the other?
You have stated that the left foot is "very pronated in the non weightbearing position and on stance it was severe, with "too many toes"sign, total collapse of the mid foot, and abduction of the foot." etc

But is it reducible? ie, is it a flexible flat foot? or more rigid/fixed? As this will determine which direction you go with any further investigation, and obviously what type of device you will prescribe.
I will be interested to hear your findings / results in the new year.
Adam

Thanks for your interest Adam. The child's foot is reducible, and some boney change is now noticeable in the talo-navic region, albeit non restrictive at this point. I am interested to hear any ideas about devices.......

Kym

Hi Kym, hope you had a Merry Christmas.

If you are dealing with a unilateral, "flexible / reducible" pediatric flat foot, then as stated earlier possible deltoid +/- spring ligament damage or rupture may be worth looking into. But, as you say the parents are not looking for surgical treatment options...
So, an orthotic device for a case like this is often very tricky as grossly pronated, flexible foot in a child is very difficult to control. Firstly obviously footwear is going to play a major role in the degree of overall control achieved, and a more "aggressive" device that includes modifications such as: a medial heel skive, minimal arch fill, slightly inverted pour and maybe a medial flare / flange with a small amount of PPT arch padding to reduce the amount of arch irritation may be useful. In my experience children can often tolerate more aggressive devices quite easily once used to them.
Hope this is helpful.
Adam

Many Thanks Adam for your useful advice. I have now reached the stage, that this is what we are going to try and the mother is happy with this intervention....not sure about the dad!! Three weeks and the device should be in place and hopefully without negative repurcussions!

Thanks again!
Kym

Hi Kim

Just a quick thought, has this young mans hips been checked for SUFE which may be causing this appearance, and would be a rapid onset?

Miranda (not J.Taylor!)

Million Dollar Question: Does this boy have any pain or true functional deficits ????

If not, I would place him in a motion control shoe, stop the chiro visits, and let him get on with being a 12 year old.

Nick

How is his spine? Any scoliosis or rotational compensations?

Thanks for the question, however the child in question has received orthoses and moved on, so I no longer get to follow him up. Kym