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Ankle ROM in six-month-old girl - advice required.

Discussion in 'Pediatrics' started by Mark Russell, Nov 8, 2004.


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    This morning I examined a six-month-old girl with extremely restricted range of motion in right ankle joint – approximately 5-10 degrees. The foot is held in a neutral mid-stance position. Radiographic examination reveals no bony abnormality or malformation. Forced extension or flexion causes obvious distress. Birth was unremarkable except that the baby was in a breached position until two weeks prior to delivery then she righted herself. Normal delivery – no forceps or suction. The left ankle ROM is as one would expect in a six-month-old baby – more than adequate. No adverse family history. No neurological symptoms. No sensory loss.

    My thoughts were that she may have had the ankle extended for a protracted period – perhaps against the womb wall – during pregnancy and this has caused contracture of the anterior muscle compartment and associated soft tissues. Is this feasible given six months have elapsed? Also, is there any other investigations/treatment that can be offered aside from gradual manipulation?

    Thanks in anticipation

    Mark Russell
  2. davidh

    davidh Podiatry Arena Veteran

    Hi Mark (others).
    I would suggest that interuterine pressure may have caused soft tissue contracture/mal-development in this limb. In an infant this young my personal preference would be gentle manipulation/stretching, and due regard to other developmental milestones

    Specific neurological tests should not be considered unless a) the limb does not begin to respond over a given period (say 3 months), or b) other developmental milestones give cause for concern.
  3. admin

    admin Administrator Staff Member

    Mark also posed this message in the JSIC Podiatry Mail List

    Several good quality replies were given there, so I am doing a cut and paste of them:
  4. admin

    admin Administrator Staff Member

    Another response on JISC Mail:
  5. admin

    admin Administrator Staff Member

    Another reply from Mark:
  6. admin

    admin Administrator Staff Member

    Some more:

  7. Paediatric Examination

    Jeff & Colleagues

    I have now had a chance to examine baby Emma once more. Jeff your intuition
    was spot on. There is no ankle movement and what I thought was ankle ROM
    was in fact mid-tarsal motion. Further I cannot manage to elicit any
    calcaneal inversion or eversion whatsoever. What I also missed during the
    intial examination was that there does not appear to be a medial malleolus -
    although I can palpate the distal end of the tibia. Compared to the left
    ankle the malleolus is absent. I have now obtained the original
    radiographic plates but they have been forwarded to me on CD-ROM and
    unfortunately my machine cannot read them. I've tried to attach them here but the file size is too large. Craig has kindly offered to link them to the site via a web page and hopefully you'll be able to view shortly. I look forward to your comments.

    Kind regards

    Mark Russell
  8. Craig Payne

    Craig Payne Moderator

  9. admin

    admin Administrator Staff Member

    Reply via JISC Mail:
  10. admin

    admin Administrator Staff Member

    Another reply:
  11. admin

    admin Administrator Staff Member

    Latest response:

    Last edited: Nov 12, 2004
  12. Paediatric Problem - CCPV & VT

    Kevin et al.

    Having thought a little more and having revisited these images again I am
    left with the feeling that this is not CCPV or VT. With CCPV the heel is
    usually elevated and the calcaneum lies in equinus and valgus. The forefoot
    is normally fixed in eversion and the plantar aspect of the foot is convex
    (with the head of the talus forming the lowest point on the medial arch).
    That is not the clinical picture here. From the lateral image I cannot see how the talus can be described as vertical. Also I am concerned about the distal
    end of the tibia. Can you look at this again and bear in mind my comment
    about the medial malleolus? If it were a congenital malformation of the tibia - possibly due to a positional intra-uterine abnormality - wouldn't this displace the talusanteriorally in the way the image shows? Just a thought.

    Thanks once again for your time.

    Mark Russell
    Last edited: Nov 12, 2004
  13. admin

    admin Administrator Staff Member

    Reply via JISC mail:

  14. If I can bring you up-to-date on the progress of the baby girl with the
    fixed ankle abnormality.

    I referred this child to a consultant orthopaedic surgeon at a leading
    children's hospital in the UK two weeks ago and forwarded the x-rays and
    clinical findings. The opinion received runs;

    "......she is a second child born at full-term by normal delivery. No
    family history. She was born with her right hip flexed up and against the
    chest but with no apparent knee of foot deformities. It took approx. three
    months for the hip to come down. It was then noted that the foot did not
    move normally. Clinically she now has full hip and knee movements both
    sides. the right foot has a normal shape, but a jog only of
    dorsiflexion/plantar flexion about neutral. Normal forefoot/hindfoot
    alignment and moves toes normally on sroking sole of foot. There is no
    evidence of thigh, calf or foot wasting. Normal body landmarks. Spine

    ....x-rays from six weeks ago appear to show normal bony elements to the
    right foot in normal alignment.

    She presents with an isolated foot contracture, possibly due to lack of
    foetal movement and this would be a very minor form of arthrogryposis.
    There is no evidence of any neurological abnormality or syndrome. In the
    first instance she would benefit from simple passive mobilisation and this
    can be supplemented by active movements when she starts standing and
    walking. With the foot in a normal alignment there is no indication for
    corrective surgery at this stage......."

    I am very grateful for this opinion, as I have been with all those who
    submitted replies on this forum in recent weeks. However, I still have
    concerns at the diagnosis and proposed management, even though I greatly
    respect the views and experience from those kind enough to offer them. If
    this is simply a soft tissue contracture, I would have expected some degree
    of movement due the elastic nature of these structures and also because the
    foot, even if it had been fixed in some intra-uterine position, has now
    been in 'neutral, for nearly nine months now, since she was born. There
    also seems to be a difference of opinion regarding the interpretation of
    the x-rays.

    I don't wish to contradict any of the contributors, or indeed this surgeon,
    but my gut instinct is to proceed with caution, especially where passive
    mobilisation is concerned. The child’s health visitor referred her because the paediatric physiotherapist could not elicit any movement during
    earlier mobilisation sessions, and on that basis I am reluctant to advise
    any recommencement of physiotherapy until I have an accurate diagnosis.

    Am I being too cautious?

    Mark Russell
    Last edited: Dec 2, 2004
  15. footfan

    footfan Active Member

    Any update on this thread?

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