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Abnormal in-toeing in 13 yr old boy

Discussion in 'General Issues and Discussion Forum' started by Leah Claydon, Nov 6, 2014.

  1. Leah Claydon

    Leah Claydon Active Member

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    :santa:Can anyone shed some light on the following presentation: We suspect some kind of ataxia and have referred him for further investigations but would be interested if anyone has come across this in clinic:

    13 yr old otherwise healthy and normal looking boy, attended clinic yesterday. Father complaining that he has started intoeing since September and starting tripping over his own feet.

    Begins when tired, after walking for a few minutes or when distracted. Able to walk straight for a while if he concentrates.

    NB; this in-toeing is new. No previous history during development.

    Hx: Recent growth spurt - 10-15 cm over summer, normal height for age and normal BMI
    extreme wear of medial heel on shoes on both shoes - as if to produce a deep valgus wedge
    Cramping like pain in triceps surae and Right peri-patellar pain
    No pins, needles or numbess, no neural tension
    RF affected more than LF
    In relaxed stance Rcalc slightly varus, Lcalc slightly valgus
    Left patella slightly valgus
    No Genu valgum
    Slight hypermobility
    Main foot obs: BF metatarsus adductus moderate to severe worse on Right
    no equinus, slight FnHL.
    No femoral anteversion
    No hip restrictions
    Found single support difficult on right foot
    flexsion and extension in knees, hips and back normal
    slight stiffness L3 and T11 and hypertonia L3-5 on right
    Slight weakness in glut med on right
    Nothing particularly remarkable anatomically except the metatarsus adductus which we appreciate is a potential primary cause of intoeing but this is a new presentation.
    Other Hx: fell out a tree onto his back last winter landing on a well rotted branch under leaves across his lower lumber area from which he recovered quickly - we don't think this is relevant.

    On treadmill at 1.8kmH (he couldn't manage faster) he started reasonably well but the gait was unpropulsive.

    He placed his feet and lifted without forefoot activation and produced a quadraceps stepping gait with lack of activation of triceps surae and short stride length. After 3 minutes the right foot started to adduct and his hallux began to adduct in an extreme way. Followed by his left foot. Worse on right. Began to lose balance and trip. Arms remained limp at sides as all propulsion originates from quads, there wasn't much vertical transmission to ilicit arm swing. Abnormal wear on medial heels is not from abnormal pronation or medial loading - it's from scuffing and lack of ground clearance.

    He is generally unstable.

    There is not any family history of neurological problems. Both parents are hypermobile.

    It's certainly very unusual. He was examined simultaneously by myself, a physio and osteopath and we are all confused.

    Any thoughts gratefully received. He's attending an appt with an orthopedic paediatric consultant next week.
  2. Bug

    Bug Well-Known Member

    Hi Leah,
    You mentioned no pins or needles etc but what was the patella reflex, achilles reflex and plantar reflex? Was there any clonus or catch during any ROMS?

    It looks like you have done a great biomech however appears to only be half the picture. Were there any concerns at or near birth etc? Rapid growth spurts in teenagers can accentuate any underlying neurological conditions that were previously quite mild.

    I hope the ortho is OK, but in my experience many forget about neurological signs and symptoms. You may want to consider a paed neuro with some blood tests as there are many systemic conditions that can cause that change as well.
  3. Leah Claydon

    Leah Claydon Active Member

    Sorry for missing out reflexes: reflexes were normal, no clonus or catch.

    Will try to post short video clip if patient consents.
  4. dhodgkin

    dhodgkin Member


    Did the hallux adduct during stance, or dorsiflex during swing phase? May be overuse of EHL compensating for tib ant weakness. I'm also bothered by the foot assymetry; it's unusual to see weightbearing calc varus in children. Sounds neuropathic. You do see presentations similar to this in later onset neuropathies such as HMSN and (hope not) Freidrich's ataxia.

  5. HansMassage

    HansMassage Active Member

    T11 attachment and /or enervation of psoas minor may be involved. In my work I find that the normal reflex is for the psoas minor opposite the leg being lifted engages to balance the pelvis. When this fails extra ground force and tensions across the hip socket are called upon to maintain stability.

    Passive palpation T11 to L1 with client prone and active walking motion gives me the best reading of what is going on.

    Supine with legs over a ball and rocking legs side to side until spine is rotated to bottom of ribs has proved to be the best method of restoring motion/activation and builds coordination/strength.

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