Evidence Essentials – Blog 4 – February, 2017
“My foot is sore” – the importance of history taking
A 10 year old, happy looking girl and her Dad were sitting and talking quietly in the consulting room. New to me, I confirmed that the child was the patient – “Yes”, she smiled, “because I have the knobbly sore foot”.
The précis of the history went something like this:
- a perfectly healthy girl, with unremarkable developmental history, and good general health
- the “knobbly sore foot” viz. prominence of the 1st metatarso-phalangeal joint (R > L) and great toe deviation, had been noticed over the “last year or so”, and recently began to hurt with shoes (no pain at all when running around barefoot).
I gave a general explanation about hallux valgus – prevalence, gender ratios, types, and associations. The obvious next step was to explore the gene pool (aka family history). “My Mum has the same sort of bumps”, said the Dad. “So does my Mum”, said the child – all laughed at that!
I asked about general joint flexibility within the family – “Does anyone have very flexible joints, sometimes this is called being ‘double-jointed’?” – and simultaneously ran through the Beighton Score (7/9 – only elbows excluded), and noted the medial knee position when standing, Grade 2 (R, grade 1 L) hallux valgus (Manchester scale), the light lanky build, flat medial foot column, slight cyanosed appearance of toes and fingers (cool to touch, >30C outside). “Her hands are always cold like her Mum’s, said Dad, “but I hadn’t noticed the same with her toes”.
Some more ‘digging’ – social history, medical history, pain history, 1st degree relatives – “Oh, her mother does have floppy heart valves – we didn’t know until she was pregnant – it’s part of a condition with a long name – and our older daughter has it too – she has had a number of joint dislocations – I’d forgotten about that…”
It transpired that both the child’s mother and sister have Ehlers Danlos syndrome. Raynaud’s phenomenon affects the mother, but not the older sister.
The priorities were now two-fold:
- An immediate intervention for the foot pain – generic foot orthoses adapted to better position the 1st mp joints, which the child liked straight away (“the bumps don’t rub”). Re-visit once priority 2 is addressed.
- Liaison with the GP re probable diagnosis of EDS, given Marfanoid habitus, or other hypermobility condition.
Evidence Essentials (Series 1, monograph 7) addresses Joint Hypermobility, and covers developmental trends, diagnostic details and differential assessment. Hypermoblity categories, clinical tests and assessment criteria are presented in clear Tables – quick and easy reference for clinicians who need on-the-spot information (Series 1, monograph 7, pp14-16). Appendices include succinct and clear summaries of genetic conditions for differential diagnoses – EDS, Marfan, Osteogenesis Imperfecta (Series 1, monograph 7, pp17-21).
Hypermobility needs to be recognized, appreciated and critically approached. Many non-inflammatory conditions may give rise to musculoskeletal pain in children, and those associated with hypermobility are common. Hypermobility per se is not necessarily a diagnosis, and often forms part of a wider diagnostic framework.
Some conditions associated with joint hypermobility can be medically serious eg EDS (vascular), Marfan syndrome (ie aortic or ocular involvement), so it is important that hypermobility is differentially diagnosed to identify the cause. Hypermobility may significantly reduce quality of life of affected children, and their parents, even when ‘mild’. Clinically the determination between joint hypermobility, joint hypermobility syndrome, genetic conditions, and pain complications are made using standardised criteria (Series 1, monograph 7, page 14).
Evidence Essentials – Series 2, will dedicate a specific monograph to history taking, to present the best useable format and tools for clinicians in the paediatric setting. This is important for diagnosis and differential diagnoses, considerations around intervention, and for discussion with parents and other medical/health colleagues. Series 2 will also address hypotonia, and its distinction from, and overlap with, connective tissue hypermobility.
Series subscribers will have received the Evidence Essentials ‘Quarterly’ – a seasonal paediatric foot ‘round up’ – the ‘Summer’ bumper edition featured 13 recent paediatric foot journal article commentaries, e-links. In the style of Evidence Essentials, the ‘Quarterly’ is pithy and pertinent – a quick read to glean the latest.
Evidence Essentials has three objectives:
- Evidence Essentials funds ‘Walk for Life’ – the sustainable clubfoot project in Bangladesh – www.walkforlifeclubfoot.org
Everyone who purchases Evidence Essentials simultaneously pays for a child’s clubfoot treatment, enabling them to walk, to go to school and have a hopeful future – thank you, what a gift!
‘Walk for Life’ recently won the BMJ South Asia Healthcare Award for Excellence in Delivering Primary Care
You may like to review our latest results.
- APERF (Australasian Podiatric Education and Research Foundation) also benefit from Evidence Essentials
- Evidence Essentials brings best evidence to paediatric podiatry practice around the world, advancing your professional development.
Please keep an eye out for the Evidence Essentials blogs – every month or so.
Thank you for supporting Evidence Essentials. The second monograph series is due mid-2017. Your suggestions and feedback are welcome!
Kind regards everyone,
Dr Angela Evans PhD, FFPM RCPS(Glasg)