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Dear All

Can anyone give help and advice regarding this unusual case.

Boy 11yrs old, presented 2months ago with bilateral foot pain. Dx posterior tibial syndrome, retrocalaneal pain, Achilles insertion tendonopathy and parents concerned about gait unusual style.

This boy had severe tightness in hamstrings, ankle equinus, uneven hip levels, right rotation of the trunk relative to the pelvis, slightly hunched shoulders and left sjoulder higher than right. All gait variations seemed to be related to tight musculature and compensations thereof. No foot misalignments or variations.

In gait core stability was very poor, left foot extreme toe in 40dgs+ and sometimes right foot toe in but never simultaneously. Springy step with early heel off and often no heel strike at all ie walks on toes but very variable and bordering on scissor gait. Extreme abductory twist with very excessive pronation. His mother complained that he always wears his socks out under the 1st mpj because he insists on screwing his feet around as he walks (not his fault or voluntary I explained). The gait is extremely variable and changes around the style described with every few steps.

EVA high density Amfit custom orthoses fitted with 9mm heel lifts, high medial flange and 2-5 f/foot post extended to sulcus (reverse motons). Mobilise ankle to 10dgs + d/flex.
Referred to physiotherapist for ‘unwinding’ – stretching – core stability exercises etc.

Good results = improved shoulder / spinal / hip posture and flexibility except for hamstrings which remain very tight. Only about 35dgs of flexion in supine postion with extended knee and dorsiflexed ankle and with opposite hip stabilised to stop trick movements. (Physio remarks that left hamstrings and right Gastroc-soleus Complex very tight)


This considerably improved gait giving fairly symmetrical heel toe gait with small toe in sometimes. Pain resolved in walking and by palpation and the boy is pleased and happy with results.
Mother also pleased with results and ordered 2nd pair for sports shoes and I will probably use a direct milled polycarbonate for this.

However if the boy walks without orthoses there is little if any change in his gait despite the much improve musculo-skeletal aspects.

Does anyone have an opinion about this and would you consider neurological referral and assessment. The gait has the appearance of mild CP type gait. There is muscle tightness but not spasticity or ataxia. There appears to be a difficulty in control and coordination of limbs in normal ambulation. The boy appears to have normal development in all other areas. Discussed with physio and she had similar thoughts about unusual gait and referral but no Dx as yet.

What do you think?

Many thanks Dave Smith

What is to be lost by making a referral to a neurologist for an Ax? If there is indeed the presence of a neurological condition is it not better for it to be identified early? If there is no neurological involvement at least you can eliminate it as a cause and examine other possibilities.

It reminds me of when I provided treatment to a boy of similar age with orthoses to aid with significant forefoot pain. The devices did what was asked of them and the family was happy, however I felt in many ways like you do now (that something else was going on). A referral to a neurologist revealed early CMT. Not only did I feel better knowing the cause of the "different" gait, but the family were also extremely grateful for having it identified early. As a result I always believe it is better to follow your instincts, especially if you have been practicing for a while.

Kind Regards

A

My first guess is that its a mild cerebral palsy - definitle get neuro consult. We have had a couple in our clinic, not as bad as your case. Both turned out to be CP, but relatively minor that no treatment (other than our foot orthoses) was indicated.

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
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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?

Craig and Andrea

Yes thanks for your replies, In my initial assessment I made a note to review and refer as necessary. I was going down the referral route but just needed a little bolster to my confidence. Not wanting to alarm my patient's parents unnecessarily.


All the best Dave Smith

I agree with the others that this probably represents a mild form of cerebral palsy and I would definitely suggest a neurological referral to the parent.

As an aside, just last week I saw 49 year old man who was a 2 sport athlete in college that also had a mild case of cerebral palsy and was in excellent condition still. His cerebral palsy certainly didn't seem to slow him in any way and, I think, his disease made him even more motivated toward his athletic pursuits.

Therefore, if this young man were my patient, I would strongly encourage continued participation in physical activity and sports as a way to increase both his physical and mental well-being.

__________________
Sincerely,

Kevin

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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
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