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Podopaediatrics (tibial torsion).

Introduction

A case history of a paediatric patient with a lower limb problem. The patient suffers from tibial torsion and this report summarises the journey of the podiatrist to its conclusion.

Parent's concern

Both the parents are worried and concerned about their only son age 7 years old, in particular, how he walks. The boy had trouble at school when engaged in physical activities which sometimes lead to sudden falls and loss of balance compared to other children. As time went on the boy started to complain of discomfort and his parents noticed his reluctance to participate in certain physical lessons. For several years they have been taking their boy to the GP looking for answers and possible treatment. Unfortunately the advice received from the family GP was 'it will correct itself'. Eventually the boy was referred to a physiotherapist, but the parents were dissatisfied with the advice. The father reached a point that he felt he had to do something. He researched using the Internet and discovered that there is a profession that specialises in the lower limb - Podiatry. He was surprised that the GP never mentioned biomechanical problems and the role of podiatrists.

The father called the clinic to seek a biomechanical opinion from the podiatrist for his child. He made an appointment and was advised that the child should wear boxer shorts / vest to facilitate the examination.

Initial Examination

The examination was conducted in the biomechanical assessment room with the child's father present. To make the boy comfortable the white coat was removed before the consultation. There were several stages of assessment: history taking, observation prone, supine, static and dynamic. The boy was then examined wearing boxer short and vest, so that the legs and overall posture could be readily examined. (Somerset NHS 2008)

Tibial Torsion Test

Prone Examination

The boy was laid on his belly face down on the couch.

Hip rotation test: to check for femoral torsion each leg in turn was flexed to 90 degrees at the knee. Rotating the legs inward and outward to observe the range of movement, the examination found no femoral torsion and the patellae were seen to be in midline.

The thigh-foot angle measurement

Secondly, checking for tibial torsion, each leg was flexed 90 degrees at the knee. Looking down from above at the feet and rotating the legs internally and externally demonstrated bilateral internal tibial torsion. Clifford R, Wheeless (2010).

Transmalleolar angle test

Normally, the medial malleolus is anterior to the lateral malleolus

"... a transmalleolar axis rotated externally less than 10[degrees] signifies interna! tibial torsion'. Patel M, Herzenberg J (2009)

A dynamic computerised gaitscan was conducted to see the degree of instep movement; the report produced a visual representation of the gait angle of inward progression toward midline (toe-in). Analysing of exanimation The history and consultation revealed that the child had no hereditary problems. Triplanar joint assessment: Talocrural joint motion for both feet was 12 degree (ROM) Subtalar joint motion for both feet was equal in both limbs, but medially displaced. Midtarsal joint: both feet presented normality. First and fifth rays plantarflex/dorsiflex normally. With the patellae straight the lateral malleolus was seen to precede the medial malleolus. Since feet and hips are normal, this indicates internal tibial torsion. After thorough assessment of the lower limb mild internal tibial torsion on both legs was demonstrated.

Treatment

There are a few options for treatment of the child's problem. To reduce in-toeing and reduce discomfort, prescription orthotics of gait plates might be recommended, (Redmond 2000) as one option, or we may do nothing as this problem may resolve itself gradually (Thackeray & Beeson 1996).

Prognosis

There is no solid evidence that any treatment will rectify the problem. Surgical intervention is not required for mild internal tibial torsion. Only in severe cases is surgical intervention necessary. (Hong Kong College of Orthopaedic Surgeons, 2008).

A high proportion of cases, almost 95% will spontaneously resolve by 8 years of age (Moses, 2010).

Mr Somuz Miah CFPodM, MFPM RCPS (Glasg) Consultant Podiatrist Prescriber

References

Clifford R, Wheeless (2010) Internal Tibial Torsion [online] Available from: http://www.wheelessonline.com/ortho/internal_tibial_torsion [Accessed 5th March 2010]

Hong Kong College of Orthopaedic Surgeons (2008) Intoeing and Out-toeing in Children [online] Available from: http://pic.hkcos.org.hk/hkcosweb/paper.jsp?id=FC7403A1C698DBE566CFC5C7052229BF&bpid=ankle [Accessed 9th March 2 010]

Moses S (2010) Internal tibial torsion [online] Family Practice Notebook, Available from: http://www.fpnotebook.com/Ortho/Peds/IntrnlTblTrsn.htm [Accessed 9th March 2 010]

Patel M, Herzenberg J (2009) Tibial Torsion [online] Available from: http://emedicine.medscape.com/article/1251352-overview [Accessed 6th March 2 010]

Redmond AC (2000) The effectiveness of gait plates in controlling in-toeing symptoms in young children Journal of the American Podiatric Medical Association 90 (2), 70-76

Somerset NHS (2008) PODIATRIC BIOMECHANICAL ASSESSMENT [online] Available from: http://archive.somerset.nhs.uk/publications/Podiatric%20- %20gen%20info%20leaflets/Podiatric%20biomechanical%20assessment.pdf [Accessed 7th March 2010]

Thackeray C, Beeson P (1996) In-toeing gait in children The Foot6, (1), pp1-4
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Article Details
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Author:Miah, Somuz
Publication:Podiatry Review
Article Type:Clinical report
Date:Sep 1, 2016
Words:836
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