Evidence Essentials – Blog 6 – June, 2017
Different congenital paediatric foot deformities – similar gait and posture effect.
Congenital talipes equino varus (CTEV) is well recognized, both clinically and in terms of consequence.
Calcaneovalgus (CCV) is perhaps as prevalent, less well recognized and of more varying and subtle consequence.
Limb length differences (LLD) may be a consequence of many lower limb conditions, with just a few common examples including:
- Fracture – epiphyseal, femoral, tibial
- Hip dysplasia
- Blount disease
As this blog illustrates, LLD may also result from unilateral foot deformity.
Case 1 – 16 year old boy with R anterolateral ankle pain, aggravated by all sports, and presented as a typical ankle impingement (unilateral). As a very keen cricket and football player, he was increasingly unable to participate at both trainings and games.
History: Right CCV, treated with serial plaster casts soon after birth, and normal development followed.
Clinical main points:
|Fore / Rearfoot varus (degrees)||Approx. 5||> 10|
|Ankle lunge test (degrees)||25||< 15|
|Tip toe test||ok||Weak, incomplete rise|
|Inversion||ok||Weak, +ve Jack’s test *|
|Single leg stance (seconds)||> 10||2-3|
|Leg length (mm difference)||0||18-20 (short)|
Gait: limp off sore Right side, R hip lower/anterior, uneven arm swing. PSIS in stance, R lower, also lower R iliac crest. Supine showed Galleazzi’s sign, and single leg stance showed Trendelenburg’s sign with unequal static balance (R<L).
Presenting foot posture (R CCV)
Galleazzi sign re LLD
Note: Ricardo Galleazzi’s sign originally related to DDH, which if unilateral, involves LLD
What do we know about CCV?
- Presents as a marked abducted/dorsiflexed (‘up and out’) foot position at birth that will not fully reduce – easy to identify if unilateral
- STJ range: eversion > inversion
- Reduced ankle plantarflexion range
- Affected foot may be dorsiflexed against anterior tibia
- Always important to consider hip dysplasia (DDH), cerebral palsy, vertical talus
- Estimated incidence 1: 1000 (inconsistent criteria, low quality studies)
- Classically, L side is affected
Prognosis (from author’s experience)
- ‘many’ reduce post uterine confinement (positional)
- ‘some’ require manual stretching (not reduced/ marked at 3-6 months)
- ‘few’ require serial casting (not reducing with stretches by 6 months)
- ‘fewer’ require surgery (if rigid)
- ‘often’ overlooked, and may present as neurologically intact early walker with marked (unilateral) flatfoot posture
Case 2 – 52 year old man presented with R ankle, knee and low back pain. Gait revealed an obvious limp. Footwear was unevenly worn, with consistent Right lateral heel/ sole wear pattern. “I am sure my Right leg is shorter and making me limp”.
History: Right CTEV, treated with serial casts and foot abduction braces as an infant and young child. This is both unusual and fortunate given the generation, when surgical correction for paediatric clubfoot deformity was the usual intervention.
Clinical main points:
|Fore / Rearfoot varus (degrees)||Normal||Approx. 5|
|Ankle lunge test (degrees)||20||10|
|Popliteal angle (degrees)||-30||-40|
|Single leg stance (seconds)||> 10||10 (painful)|
|Leg length (mm distance)||0||25 (short)|
Gait: Right foot adduction and inversion with forefoot loading, R hip lower, hips rotated in transverse plan (Right forward). Supine showed Galleazzi’s sign. In stance, 20-25 mm ‘blocks’ under R foot leveled PSIS. Use of 10 mm full length raise in Right shoe, provided immediate symptom relief.
Galleazzi sign (note smaller R foot and calf girth, re CTEV)
‘Reverse’ Galleazzi sign re LLD, involving tibial segments
What do we know about CTEV?
Evidence Essentials Series 1, monograph 6, addresses the contemporary evidence-base for CTEV ( www.evidenceessentials.com )
CTEV – marked adducted/varus/plantarflexed (‘down and in’) foot position at birth that will not reduce, often a plantar foot crease, and always ankle equinus – again, easy to identify when unilateral
- Presents as a marked adducted/varus/dorsiflexed (‘down and in’) foot position at birth that will not reduce (less frequently some CTEV are milder ‘postural’ cases) – easy to identify if unilateral, but is usually bilateral
- STJ range: inversion (minimal, if any, eversion)
- TNJ subluxation
- Ankle equinus
- Affected foot (if unilateral) is often smaller
- Always important to consider DDH, cerebral palsy, congenital syndromes, spina bifida, arthrogryposis (AMC)
- Recent estimated incidence 1-2: 1000 worldwide
- Classically, R side is affected (if unilateral)
Prognosis (from recent research and author’s experience)
- Lifelong disability without treatment
- Non-surgical Ponseti method is the current global ‘gold standard’ intervention
- Not a homogenous condition
- Relapsing deformity in approx. 20% cases (repeat Ponseti treatment…)
Limb Length Difference – calling Galleazzi (and/or Allis), Trendelenberg, and a stack of books!
The main clinical considerations include:
- is it a ‘real’ LLD ie structural; or has it become unequal – weak hip abductors, scoliosis, uneven hamstring lengths etc – OR as with these cases, resulting from unilateral foot deformity?
- Is the child neurologically intact?
- In younger children, always consider DDH
- Whilst scanograms are the LLD ‘gold standard’, clinical assessment using books or blocks under the short leg to level the pelvis has been shown to be a reliable clinical test for LLD – assessing PSIS level in stance (ICC 0.83 = Terry et al: https://www.ncbi.nlm.nih.gov/pubmed/15718901 )
(Clinically, I use stacked 3.5mm plexidur plates – a remaining use for this historic orthotic product!)
Remember: marked asymmetry is an unexpected clinical presentation – be it foot posture, gait, limb morphology, motor skills – so work it out methodically as part of your diagnostic work up.
Evidence Essentials – Series 2, monograph 1 is dedicated 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.
NEXT BLOG TOPIC
Perhaps it is time to consider the difference between foot deformity versus foot position at birth?
Let’s not keep the same old references and statements appearing without critical review.
This will be addressed in the next Evidence Essentials blog, with components already covered in Evidence Essentials Series 1 and the soon-to-be-released Series 2.
Evidence Essentials is a non-profit education project, with three objectives:
- Evidence Essentials brings best evidence to paediatric podiatry practice around the world, advancing your professional development.
- 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’ won the BMJ South Asia 2016 Healthcare Award for Excellence in Delivering Primary Care https://www.facebook.com/bmjindia/posts/1568615189820514:0
You may like to review the recent WFL publication: : http://jfootankleres.biomedcentral.com/articles/10.1186/s13047-016-0175-0
- APERF (Australasian Podiatric Education and Research Foundation) also benefit from Evidence Essentials
Please keep an eye out for the Evidence Essentials blogs – every month or so.
Series 2: available July-August-2017.
Thank you for supporting Evidence Essentials, ‘Walk for Life’ and APERF.
Dr Angela Evans PhD, FFPM RCPS(Glasg)