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Just wondering if anyone has any experience with non-surgical treatment of asymptomatic crossover toes? I have a young patient who was born with the 2nd toe crossed over the 3rd toe bilaterally. The mother reports that the 5th toe used to overlap the 4th toe quite severely but this has corrected 90% without assistance. The deformity is fairly easily reduced manually, and slightly reduced alone during weightbearing. The patient is having no other problems with pain or loss of function, her great grandmother apparently had the same curly toe deformity at the 2nd toe bilaterally.
The mother has been taping the toes straight at night for the past 4 weeks, and there has been a mild improvement... Does anyone have any better ideas regarding splinting the toes? Or is this something that would be best dealt with surgically when the child is older?
On bad days i feel i do nothing else but try to reassure parent that little tommy will NOT end up in a wheelchair because they have curly toes!
I have never found anything which i can say works with any degree of confidence. Sometimes there seems to be elements of flexor stabilisation going on which seems to respond to orthotics but i would definatly not swear to that!
I tend to use budlin type splints rather than silicons, they seem to work better for me. They also require less work on the patients part than strapping.
I usually tell the parents that:-
A. There is a good chance the toes will self resolve
B. There is a considerable amount of "genetic inertia" at work, that feet vary in shape just as do faces and that curly toes might just be "normal for tommy" just like his big nose or satalite dish ears (sometimes i'm more tactful)
C. We cannot operate on toes on children under the age of 18 anyway because of the nature of the bones. All we can do is keep them in as good a position as possible and then operate later IF NEEDED
I do think there is some benifit to trying to keep the toes as "in line" as possible. The causes of curly toes are varied but regardless, if a toe persistantly over rides, Davis law would suggest that the dorsal tendons will shorten and entrench the problem further. Keeping the tendons stretched so that the toe CAN adopt the desired position (even if it only does it when the device is being worn) therefor has some value IMVHO.
This is also a concept that parents can get behind. Even giving them stretching exercises makes them feel they are doing SOMETHING and helps prevent the "i'm being fobbed off" thing they get when they come in with a condition you cannot treat.
I'm glad you started this thread. I'm hoping somebody has a better idea than me!
I tend to agree with robert that reassurance is one of the most important , and perhaps difficult jobs when it comes to "curley toes" in children, but the more you can educate the parents the better.
I have used mouldable silicone such as otoform with differing results.
For the very tiny totts it is a nightmare just trying to mould it let along get them to stay in place in between attempts of the child to eat it or their toes or my tie or the sticky lolly that mum just gave as a distraction.......! for the older children it is easier but whether it makes long term significant differences i do not know.
I am interested to know what these Budlin splints are though please robert - new to me?
The only thing I would add to the debate, apart from educating the parents, is not to get into a battle with the child over any treatment, children of that age can be incredibly manipulative with the net result the parents often feel guilty that they are not helping little Tommy or Jemima.
As said in previous threads the heel / toe gait is not established until about 6 years of age and the reverse windlass which assists in toe purchase can often 'flatten or straighten' errant toes.
By the time the child is seven or eight they have a better understanding of the problem (if there is one left) and become involved in the strapping, silicone use etc. I have had mixed results, but at the outset explain to both parent and child it may work, but it may not, but I will work with them. The mere fact you take the problem seriously, and try something is seen, in my experience anyway, in a positive light by the parents.
Oh and one thing I have learnt, partly from experience and partly from discussions on here, take photo's or sketch the deformity, very useful to refer back to, to see if there is any improvement (with / without treatment).
I'll be speaking with the mother again next week, and will relay some of the new info I have now... By the way, the patient is surprisingly cooperative with having her toes taped at night, she even reminds her mother if her toe tape is forgotten!
I did some work a while back on non surgical straighening of lesser toes using serial toe props made in silicone putty for the three middle toes. The setting silicone (putty) is applied to the toes with the suspended foot set in a sub talar neutral position (as in casting).
No attempt was made to change the toe positions by traction (as recommended by Budin, and Black and Coats), instead dead space was used. Toe space 1/2 and 4/5 are natural gaps and allow retaining 'lugs,' when the toe close naturally. The platform under the three middle toes runs paprallel to the heel and three middle metatarsal plains (set in stj neutral). The key was to use these devices as serial orthoses (toe posts) and that way you could maintain (muscle tone?). I used the previous device as a record of individual toe position and was able to build up a measurable (quantifiable) improvement over a period of 36 week. (that is 6 devices applied at 6 weekly intervals). The approach was used in a linear study on adult RA patients and provided the devices were worn this appeared to delay gross digital deformity (in groups considered to be prone to gross subluxation).
My experience with working with young children is shared by many and that is the child's natural curiosity often means interventions fail. But a three year old should provide an ideal canadidate, particularly is there is no sign of OA and the QOM and Quantity of Motion of the joints are not impaired. In the event the toe position self corrects then you have the psychological advantage of helping reassure all concerned the child's feet received the best passive non invasive attention.
The procedure I recommend using does not involve a pull and set approach (such as slings etc) but instead uses GR forces to engage turning moments to increase tone of intrinsic and extrinsic musculature. Shared insertions to 1st and 5th toes usually ensures what benefits acrue to the middle three toes are shared.
Obviously the three toe prop (toe post) is compatable with foot orthoses (as and when they are recommended).
I wrote up related information in the British and Australian journals (which includes a review of digital therapies). Others have conducted pilot trials (mainly undergrad thesis) from Finland to Australia and to the best of my knowledge, all appear to attest the approach. More recently a colleague and myself tried to have published a set of case histories in several professional podiatry journals but were rejected because orthodigital therapy was considered (by whom?) to be common knowledge.
Thanks for that info, I did try making silicone props for the child, very similar to how you described but I failed miserably due to (as you have mentioned) the patients curiousity... Apparently 3 year olds find it very difficult to sit still without moving their toes when soft silicone is placed on their foot... I tried several times to make these props, but admitted defeat after producing a series of odd shaped props...
I will be seeing this patient again shortly, so will report any advances should they occur...
I know the feeling well but as a last resort try them as night splints. If kept on even for a short time, nocternal leg movement will cause the toes to meet resistance and this may get the wee person used to wearing them during the day. Always worth a try.
As others have mentioned on this thread RE: children are very quick at realising the power adults unwittingly provide them with. Some children with conditions which provide few if any problems become drawn into their parents world of worrying over any deviation from what may be considered the 'norm'.
Quote:
Originally Posted by Donna
Hi Robeer, Cooking and Nikki
... By the way, the patient is surprisingly cooperative with having her toes taped at night, she even reminds her mother if her toe tape is forgotten!
Thanks again,
Regards
Donna :)
That isn't to indicate that I disagree with any of the treatments advised by others on this thread, I too am reading with interest about devices I have previously not encountered (love this site) :)
I do try though wherever possible to attempt to allay parental fears but try to advise that parents don't over indulge childrens need for attention.
Not curly toe related I know but one patients mother (pt. was 3) Said all child talked about from sun up to bed time was the vp on his toe. (non painful vp of 4 weeks duration). Reassured mum vp was fine & gave long explanation to allay her fears of childs leg falling off in sleep, but advised mum that lil lad was becoming obsessed by toe because every time a family member, neighbour or passing salesman passes by the child was instructed to remove sock & show his toe!
Hope this hasn't come across as negative to parents, it wasn't intended to.
Regards,
__________________
:)
twirly
Mandy Brooks
Brooks Podiatry
S64 0DE
Suffering a fondness for odd things.
Curly Toes in 3 year old girl
I think I searched for everything but...
)
I tried several times to make these props, but admitted defeat after producing a series of odd shaped props... 
Linear Mode
