Lower Extremity Disorders

1. Lower Extremity Disorders By: Joel Hallam, OMS III GA-PCOM Class 2011

2. Common LE Disorders Congenital Club Foot Metatarsus Adductus Flat Foot or Pes Planus Idiopathic Toe Walking Tibial Torsion Femoral Anteversion

3. Congenital Club Foot In-towing with inversion of the entire foot Pathogenesis: Unclear, but believed to be multifactorial Presentation: Can be identified as early as 12 weeks gestation Definitive diagnosis made clinically Equinus Positioning Cavus Position Metatarsus Adductus Hindfoot Varus � Separates from Metatrsus Adductus

4. Club Foot (cont.) Treatment: Ponseti�s Technique Series of casting which gradually place the foot in the correct positioning Achilles Tendon Lengthening Accomplished via stretching and excercises Denis-Browne Bar and Special Shoes Bar maintains correct alignment after casting Shoes are worn nonstop throughout the first few months Following this treatment course has reduced surgical involvement down to less than 10% Surgery involves an open posteromedial release

5. Metatarsus Adductus Adduction or Medial Deviation of the forefoot relative to the hind foot Pathogenisis: Nonspecific, but could be associated with: Muscle imbalance in the foot Congenital medial cuniform deformity Subluxation of the tarsal-metatarsal joints Also could be associated with �Molded Baby� Syndrome Hip dysplasia, MTA, Torticollis

6. Metatarsus Adductus Presentation: Diagnosis is made clinically, no definite need for imaging. Convex lateral border of the food Medial instep crease and deviation of the forefoot Severity is determined by placing a straight edge in the middle of the heel and seeing where it intersects the forefoot Treatment: Manipulation and stretching < 15% require special shoes Good Prognosis, but if lasts > 6months of age refer to ortho

7. Pes Planus Flattening of the medial-longitudinal arch of the foot Common until age 6; Can be considered a normal varient Pathogenesis: No real abnormality unless remains persistent This occurs in only 10-15% of all Americans Presentation: Medial-longitudinal arch collapse upon standing Lateral positioning of the heel upon toe standing Hindfoot does not invert upon toe standing Can be indicative of other disorders like tarsal coalition, inflammatory arthritis, peroneal spasm

8. Pes Planus Treatment: No treatment is indicated for children < 8 years old In teenagers, a tight heel cord diagnosis leads to a stretching routine Orthotics are used only if pain persists Ortho referrals are rare and are only indicated if pain is persistent

9. Idiopathic Toe Walking Presence of toe-to-toe gait past the age of 3 Typically experimental and normal gait should start at 4 years Presentation: Normal exam Tip-toeing when walking In cases of abnormality, Achilles Tendon tightness needs to be checked Later in life, Gait analysis and Blood testing All normal in ITW Differential Diagnosis: Cerebral palsy, Duchenne Muscular Dystrophy, Autism

10. Idiopathic Toe Walking Treatment Check heel cords Stretching of Achilles Tendon After 4-5 years old, casting can help Weakens gastrocnemius allowing full stretch Botox injections Most non-resolving situations are handled by Orthopedist

11. Tibial Torsion Rotational deviation of the tibia that causes the foot to malalign with the knee Pathogenesis: Internal Tibial Torsion Commonly due to intrauterine positioning Left is more common than right A/w bowleggedness in children who walk within 8-9 months External Tibial Torsion Usually compensation for a femoral anteversion Also seen in children with Cerebral Palsy and Myelodyspasia

12. Tibial Torsion Presentation: Frequent tripping in 1-3 year olds with in-toeing Measured by calculating the thigh-to foot angle Normal is 10-15 � of external rotation relative to the thigh Any rotation inward is considered Inward Tibial Torsion External rotations of >20� is considered External Tibial Torsion Radiographs are not typically needed CT can help in surgical candidates

13. Tibial Torsion Treatment: Internal Tibial Torsion Usually resolves by 5-6 years old External Tibial Torsion Usually persists and could get worse Surgery to correct the rotation maybe indicated if persist >6 years old Persisting torsions should be referred to an Orthopedist

14. Femoral Anteversion Tilt of the femoral neck in relation to the shaft of the femur >20� Retroversion is <10� Normal Femoral Neck is 15� Pathogenesis: At birth newborns have a 40 � of anteversion As we age and grow it reduces to within normal limits at about age 12 It may persist in children with Cerebral Palsy, or congenital joint laxity conditions. Presents: Any child in-toeing after the age of 3 should be evaluated Clinically best analyzed from prone position

15. Femoral Anteversion Clinical Signs: Extreme internal rotation of the hips >60-65� Retroversion if < 20 � Limited external rotation of the hips Treatment: Anteversion usually resolves by 10-12 years old Surgery is indicated in severe cases Growth helps remodling �W� Sitting is controversial as it may delay natural healing

16. Resources Smith, Brian G. �Lower Extremity Disorders in Children and Adolescents.� Pediatrics in Review. Vol. 30 No. 8 p. 287-293. Used Jan 27, 2010 Robertson, Jason. Shilkofski, Nicole., The Harriet Lane Handbook: A Manual for Pediatric House Officers. 2005. 17th Ed.