Pediatric In-Toeing

In-toeing is a common complaint among parents who's children are at or near walking age.  It will frequently bring parents in with their young children, who may say that the child “walks funny” or is “pigeon-toed”.  It is most often noticed by the parents as the child begins to watch, typically around 12 months of age, but may present at anytime during childhood for various reasons. 

In-toeing, particularly in children less than 8 or 9 years old, is usually harmless.  It may represent a normal variation of anatomy and development, and will usually resolve with time.

However, what often brings parents in to the specialist’s office is that their child walks with limp, trips over their feet, is in pain, or has difficulty keeping up with their peers.  In these cases, a through evaluation of in-toeing is warranted by the specialist.

Of the many things that may cause a child to walk with their toes pointed inwards, there are three things that are seen most often.  These are internal rotational positions of the hip, leg, and foot. 

In the hip, femoral anteversion may cause the child to have an in-toed gait.  This is a condition whereby the femur is rotated inwards.  At the femoral head, where the bone inserts into the pelvis to create the hip joint, an increase in internal rotation can cause this to happen.  It is typically most noticeable around the time a child begins Kindergarten, at about 5 or 6 years old.  The child may “W” sit, where they sit with their legs behind them, putting pressure on the legs.  This can reinforce the malaligned position of the femur, and is typically discouraged in children with mild femoral anteversion. 

Most cases of femoral anteversion will resolve over time, reaching a normal position by the time the child is 10.  For severe cases, surgery may be necessary to cut the femur bone and rotate it into a more normal position. 

Working down from the hip, the next level that may cause pediatric in-toeing is in the leg at the tibia-fibula segmnt.  Internal tibial torsion is normal until the age of 2, where as the child walks the tibia begins to untwist.  The leg usually normalizes by the time the child is 10.  For severe cases of internal tibial torsion, resulting in significant disability or pain, surgery may be required to cut the tibia and fibula and realign them in a more normal position.

In the foot, a positional deformity called metatarsus adducutus may contribute to in-toeing.  This is commonly seen at birth, and may represent a normal variation.  In severe cases, treatment may be required to straighten out the foot.  Typically conservative measures are used first, such as straight-lasted shoes or specialized bars and braces that help to straighten out the foot.

If conservative therapy fails, surgery may be required to straighten out the foot.  However, this is reserved for severe, unrelenting and rigid cases.

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. 
Winter Haven, FL 33881 
Phone: 863-299-4551 
www.FLFootandAnkle.com

Could Poor Circulation Indicate a Looming Heart Attack?

Do your feet and legs cramp when walking?  Do you have pain at night when laying down or when your feet are elevated?  If so, you may have a condition know as peripheral arterial disease.

Peripheral arterial disease, or PAD, is a condition where the arteries of the lower extremity become narrowed due to plaque build up and/or stenosis of the arteries. Plaque build up, or atherosclerosis, is when cholesterol and other substances in the blood cause debris to stick to the insides of the artery. Over time, this can narrow the artery, much like grime can narrow the plumbing in your home.

Symptoms of PAD include cramping upon activity in the calves, thighs, or feet. This pain is usually reproducible with a certain distance, and is relieved with rest. Other signs of PAD may include hair loss in the feet and legs, coldness in the toes, color changes in the feet with a change in position, and absence or weakness of pulses on physical exam.  Sometimes people with peripheral arterial disease will say something about having “bad circulation”. 

Left untreated, peripheral arterial disease will get progressively worse as the arteries continue to narrow.  Pain can increase in frequency, and the distance that a person will be able to walk without pain will decrease.  Poor circulation in the feet can also lead to poor wound healing and areas of gangrene development in the toes.

Risk factors for peripheral arterial disease include smoking, obesity, high blood pressure, high cholesterol, and diabetes. Advanced age can also contribute to the development of PAD, as well as inactivity.

The diagnosis of PAD is made through a detailed history and physical exam, which should include checking pulses to the feet and inspection for other signs.  Often non-invasive vascular testing is ordered in the clinical setting.  This involves putting blood pressure cuffs up and down the legs at different levels and measuring the pressure difference through the leg.  This can help isolate the area of disease.  The amount of oxygen reaching the toes can also be measured clinically, which can also help monitor the disease. 

For patients with peripheral arterial disease, screening for plaque build up in all parts of the body is essential. Atherosclerosis is a systemic disease, and the coronary arteries supplying the heart and carotid arteries supplying the brain can also show signs of disease. Unaddressed, this build-up can lead to heart attack or stroke.

It is for this reason that it is incredibly important for patients with risk factors to be screened for PAD.  The risk of heart attack and stroke associated with peripheral arterial disease has been well documented.

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. 
Winter Haven, FL 33881 
Phone: 863-299-4551 
www.FLFootandAnkle.com

Os Trigonum Syndrome

The os trigonum is an accessory bone found in the posterior foot.  It is seen directly behind the lateral tubercle of the body of the talus in 2.5% to 14% of people.  It is a round, triangular, or oval shaped bone that is variable in size, but is typically quite small compared to the surrounding bones.

Os trigonum syndrome may be seen in people with the anatomical variant, and presents as pain in the back of the ankle.  This is due to impingement of the bone, and the condition is sometimes referred to as a posterior impingement syndrome.  Pain may be reproduced when the patient goes up on their toes, thus adding pressure to the posterior ankle.  This is particularly noticeable in ballet dancers or in athletes that spend time on their toes. 

Diagnosis of the condition is made largely on clinical suspicion and presentation, and is confirmed with x-rays.  The accessory bone may be seen on x-ray.  In conditions where the bone is not seen on x-ray, an MRI may be ordered to further assess the area.  MRI may show a separation between the body of the talus and the accessory bone, as well as any swelling in the area. 

Conservative therapy such as rest, ice, and orthotics may be beneficial to some, although surgical excision is usually necessary to relieve the symptoms.  The accessory bone may be removed completely, in an attempt to relive pain and restore function.  For the competitive athlete or ballet dancer, this may mean a period of rest from activity while their surgical site heals. 

Os trigonum syndrome should be differentiated from other possible etiologies of pain, such as tendinitis of the flexor hallucis longus tendon, which runs in close proximity to the os trigonum.  Fractures and osteochondral defects of the talus should also be ruled out, particularly in cases with a report of trauma to the area.  Space-occupying lesions such as soft tissue tumors (usually benign in nature) should also be ruled out, particularly when there is no evidence of accessory bone on plain film x-ray.  The entire foot and ankle complex should be thoroughly evaluated for an other sprains and strains that may be present.

Remember that pain is an indication that something is wrong, and should never be considered “normal”.  Athletes are notorious for “playing through the pain”, but should be evaluated by a foot and ankle surgeon for any acute or chronic pain that they may be having.

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. 
Winter Haven, FL 33881 
Phone: 863-299-4551 
www.FLFootandAnkle.com