Navicular disorder in 4 year old boy

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Hi everybody,

I was hoping for an opinion on the naviculars in this nearly-4-year-old boy...

Medical history: PDD-NOS (not otherwise specified) autistic disorder, has been seeing speech therapist since age 2, patient not able to communicate or express himself, he can use some words, mainly "no", adapts poorly to changes in routine.

Patient has had an intermittent limp for the past 2 months, mother would touch the patient's foot and he would scream. This problem seemed to subside for a short while, then recurred recently. The family noted the patient walking "funny" and also noted the patient would sit with the right leg in a laterally rotated position.

The patient's mother found him sitting on the floor screaming and pointing at right foot the day before the initial visit, and thought that he may have tripped over or fallen.

On examination:
General:
- tight calves
- inverted heel strike
- mild forefoot valgus (approx 2 degrees everted)

Stance:
- significant medial deviation of rearfoot axis
- tip-toe rise: corrects well
- deep squat: MLA contacting ground
- everted RCSP (5 - 6 degrees)

Tender On Palpation:
- pt unable to effectively communicate on this
- tested navicular / post tib tendon & belly
- non-responsive, but not pushed away either
- normal feel to all these areas

We have ordered x-rays which show delayed ossification of the navicular and medial column for a 4 year old child. There are no definitive signs of AVN... but what do others think of these x-rays? We are fitting the child with functional orthoses to help normalise the forces on the child's growing feet, but is there anything else you can suggest... any other tests we can perform?

Thanks for your help,

Regards

Donna

PS: I hope the images upload ok...

 

He is in the right age group for Kohlers (see this), but not sure if its too early to see any asymmetry in the navicular ossification on x-ray (which is usually what I would expect to see). I am sure Bug would love to comment on the autistic side of the equation, so will message her.

 

Hi Craig,

Thanks for that, we've just been scratching our heads because the whole medial column of the right foot looks a little underdeveloped compared to the left foot... The patient has significant biomechanical issues that could account for the pain in his right foot (ie. medially deviated STJ axis and extremely pronated stance and gait = increased tensile strain on posterior tibial tendon and insertion).

I'll be very interested to hear more about autistic disorders, and how these patients express pain (something we didn't see much of at uni)... The "screaming" pain does seem to point to Kohler's, however I know that we need to make special considerations here due to the PDD... :dizzy:

Regards

Donna

 

Donna

I would assume it to be Kohlers until proven otherwise.

If you feel it is worth trying for compliance, perhaps a CAM walker - otherwise a below knee cast for 6/52.

Autism or not...it will need to be immobilised and the parents aren't going to enjoy it (on top of everything else they have to deal with).


LL

 

Hi Lucky!

Thanks for your advice, very much appreciated... :drinks I'll have to keep you posted with how this little guy responds to treatment!

Regards

Donna

 

Donna:

I would not put this child into a cam walker brace or cast due to his developmental and emotional issues. I would initially fabricate a modified insole pad for the foot with a medial heel skive and good medial arch support with 1/8" adhesive felt. Then I would dispense the medial heel skive, inverted, deep heel cup, thick heel contact point orthoses into a high top lace-up boot that the patient should walk in and avoid any barefoot activity and especially barefoot running. I would also add a 1/8" thick forefoot extension plantar to the 4th and 5th metatarsal heads to the topcover of the orthoses to reduce the compression loading forces through the navicular. This should not only reduce the child's pain within a week but will also allow the navicular to develop more normally. I discussed abnormal navicular compression forces in children's flatfeet deformity with medially deviated subtalar joint axes in my chapter on conservative treatment of flatfoot deformity from 16 years ago (Kirby KA, Green DR: Evaluation and Nonoperative Management of Pes Valgus, pp. 295-327, in DeValentine, S.(ed), Foot and Ankle Disorders in Children. Churchill-Livingstone, New York, 1992).

 

Hi Kevin,

Thanks a lot for your reply and that beautiful article, you always draw such fantastic diagrams!

Do you think that the abnormal compression loading forces on the navicular could account for the presence of developmental asymmetry in this boy? Would you suggest follow up x-rays after treatment is implemented, and what would be a reasonable follow up time for these? 6 months? 12 months? We've been having difficulty finding literature that encompasses the asymmetries that we are seeing in this patient...

Thanks for your help!

Regards

Donna

 

Donna:

What asymmetries are you specifically speaking of??

 

Hi Kevin,

Sorry, I should have been more specific... the medial column in the right foot seems to be less well developed that the left foot. Is this normal? We thought the x-rays looked quite different with regard to the stage of development with left and right feet... or is this asymmetry common during normal growth?

Regards

Donna

 

Donna:

You must have better eyes than I do since I don't see any significant asymmetries in the radiographs you provided in this "almost 4 y/o" child. What I see appears normal for this age......a mostly cartilagenous navicular on both feet. Ossification centers commonly are asymmetrical in appearance in developing feet. The navicular ossification center appears between the ages of 3 and 5.

 

Hi Kevin,

No, my eyes are certainly not better, they're just many years less experienced than yours... I haven't actually seen too many x-rays of 4 year old feet, so it's been greatly helpful that you could have a look and confirm that they appear normal for the age of the patient, regardless of PDD... Thank you so much for your help, it's very much appreciated! :drinks

Regards

Donna

 

Thanks for the message Craig.

I agree about the cam walker - stay away from it with this little boy. Also agree with Kevin on the radiology aspect. Do some googling on pediatric feet x-rays and ossification centres and you should get some good references for normals.

I would also be very cautious about how to progress with anything in his shoes. I presume he has an OT working with him. If so, best contact them to see how he is with change and sensory issues.

Children with any autistic spectrum disorder will always have issues with change and generally will with any touch/pressure. Which makes anything in the shoes a challenge.

Chat to mum about how he tolerates new shoes to gauge how he will respond to anything you place in the shoe. Then go slowly. I will often use a thin layer of felt and get the mum to drop the shoe in each week for me to increase the thickness. Once the thickness has been achieved and tolerated then changing it to eva etc.

Prior to putting the shoe, if he will let you or mum some pressure through the bottom of the foot, ie - with the palm of your hand, pressing the heel and the forefoot onto it. Then the shoe on and do the same, all before letting them stand in the shoe .

Sort of prepares them for a change.

If you run into a few obstacles, just take it a step back or chat to their OT so help as it can be a little tough especially if he is stuck in the "Anything to do with my foot hurts" phase.

Good luck and give me a hoy if you get stuck. If I can't help have some colleagues that will have more ideas.

 

Hi Bug,

Thank you so much for that info... I'll take that all on board when I see the patient again this week... I'll keep you posted with how we go...

Regards

Donna

 

Hi Bug,
Do you have any resources you would recommend for a clinician interested in expanding their knowledge in this area? Podiatry specific would obviously be wonderful, but failing that, maybe something with advice on assessing and managing?
Thank you,
Helen.

 

Hi Helen,

My best advise is try to understand the behaviours and then modify your treatment based on that.

I have never come across anything podiatry specific, generally it is OT or psych.

I would google Autistic spectrum disorder or the general autism websites for general info to start. For sensory related problems there is a couple of books written for parents that are great for clinician's that haven't had much experience in the area. "The out-of-sync child" and "Living Sensationally".

This is not something we can diagnose and assess. Diagnosis and assessment is via standardised assessment tools that you need quite specific training. Diagnosis of autism and some of the more specific disorders are via 3-4 trained professionals - generally OT, Psych, speech and paediatrician. All having their own assessments.

As a podiatrist we then either see a child with a biomechanical problem that is or isn't related to the behaviours of the diagnosis. It is in understanding the cause that you can tailor your treatment and managment, if that makes sense.

It is so very complex and just when you think you have a handle on it along comes another treasure that throws you a curve ball. A good alliance with other paed allied health practitioners definitely helps.

If you have questions though just give me a hoy, if I can't answer them will pass them along to colleagues that should

Cheers
Cylie

 

I'm currently doing a once a month clinic at a community paediatric rehab service and really enjoying the challenge, role and exposure to the range of conditions (not just curly toes and intoeing for a change...)
More frequently the physios (and once an OT) have been referring ASD clients, and occasionally I have struggled to complete my assessment as my usual approach failed miserably! I will do as you have recommended, hunt down those books, and try and find some time to discuss techniques or tips with the other allied health staff there.
Thanks for your prompt reply, I look forward to your future posts

Helen

 

hmccausl said "and occasionally I have struggled to complete my assessment as my usual approach failed miserably!"

Trust me, your not alone.

We have found that the first consult with most Autistic children can just be a visit rather than anything else, just getting them use to you and the new environment, trust can be a real issue especially if you are going to touch them as Bug has pointed out, although some (rare) just stand there looking at the fish swimming in the tank while we get on with the job.

We had one child that on his first visit held his breath until his lips went blue and passed out, for me "real scary" for mum just another day, after 4 visits we got around to actually taking his shoes off, an interesting case as he was assessed as "No communications" then some one introduced sign language wow what a difference to that little boy and his mothers life.

 

David, we often use a "social story" with children prior to the visit. We have a standard one that have be customised to what is going to happen on the first visit. Most parents use a lot of these as it is something the speechies introduce early in therapy. It was developed by the Melbourne Paed's Podiatry Special Interest Group.

If you want a copy and chat about how to use it, just let me know.

Helen, that sounds like a great opportunity. If you can and want to expand your skills try and get in on a few clinics together. They learn about you and what you can offer and you learn about how they work. It is a heap of fun to work in a team like environment.

 

l dont need to think about that twice, yes please Bug, we have a local school for children with Autism and we see quite a few for footwear.

Is it possible to get an invite to the Melbourne Paed's Podiatry Special Interest Group?
There is so much to learn and l take any and every opportunity to do so.

 

David - will pm you about it!

 

Hi all,

I've been meaning to post to let you all know how this little guy has been going, but I always get sidetracked with other things so sorry for the delay...

We reviewed this patient nearly a month ago, and this was a 6 week review following his orthotic fit appointment. We'd fitted EVA full length devices with a medial heel skive and deep heel cup with heel raises into some very supportive boots.

The patient's mother reported that it took 2 weeks to get the child accustomed to wearing his new boots and orthotics, it was difficult however to keep it all together initially as the patient would remove the orthotics and heel raises and play with them (particularly the self adhesive heel raises getting stuck onto various household surfaces) . After the initial "getting used to it" period, the patient is wearing the boots and orthotics to kindy and at home with no objections. I'm not sure what normal adjustment periods in children with PDD are but I assume that the important factor was that mum let the child play with the boots/orthotics and become familiar with them in his own time...

There is now no incidence of "screaming pain", no pressure spots from the orthotics, and the patient's mum reports he "isn't walking funny anymore". There is still pain on direct palpation of the right navicular, however no pain (according to patient) during walking and day to day activities. He was given some exercises to improve posterior tibial and calf strength (tip to rises), and will be reviewed after 3 months...

I'll try and keep everyone updated with what happens next...

Regards

Donna

 

Donna:

Thanks for the followup on your patient. This is very important followup information for all the clinicians that are reading these cases and that don't have the clinical experience that some of us have in treating these types of cases.

I just wish all the others that we had helped with their patients on Podiatry Arena would be so kind to keep us informed as to their progress.

 

That's great Donna, what a good result. In my experience there is no normal adjustment period. For some it is days, others months and just when you get it all right, they go and grow and you need to start all over again. But you are right, being guided by the main care giver is very important.

 

Hi Bug,

Thank you so much for your advice re: PDD. :drinks It was really helpful to know that kids with PDD adjust more slowly to change... it's not something that I remember being discussed at uni, and it's great to hear from more experienced practitioners to learn how to work more effectively with these patients!

Regards

Donna