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Intoeing and stretching

Discussion in 'Pediatrics' started by Lauren84, Aug 25, 2010.

  1. Lauren84

    Lauren84 Member


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    Do you offer stretching for intoeing gaits?
    Ive heard people doing hip external rotation stretches when changing their babys nappy.
    Any advice appreciated??

    Thanks
     
  2. Hi Lauren,

    You might find different age groups will define what type of exercise.

    I have no research to back up these claims, but Ive had good success with childern of 3-7 with hip external rotation exercise - ie parent controlled.

    For the kids abit older look at the medial hamstrings as well, I find often than the medial hamstrings are short and that hamstring stretches have great results.

    Hope that helps.
     
  3. Lauren84

    Lauren84 Member

    Thanks Michael, Great help!
     
  4. Craig Payne

    Craig Payne Moderator

    Stretching exercises will work brilliantly if the in-toe gait is caused by a soft tissue contracture at the hip (...more often than not, its not caused by that)
     
  5. musmed

    musmed Active Member

    Dear Craig
    I agree with you. It works in a minority of cases but when it does it works very well.

    I use the stretching of these muscles along with a mobilisation of the atlanto occipital joint on the opposite side to the intoeing dominant side.

    Although I ahve only a small number in the study I am getting some encouraging results. The one who have done best, immediately stop intoeing after the joint is mobilised.

    Regards
    Paul Conneely
    www.musmed.com.au
     
  6. Lauren:

    I recommend a change in sitting position to an "Indian style sitting" and away from a "W-style sitting". In addition, I recommend activities/sports that encourage external hip rotation with all children with intoeing (e.g. riding toys in younger children and roller blading/roller skating/ice skating in older children). Even though the level of the intoeing deformity may not primarily be at the hip, it can't hurt to make the internal hip rotators and joint capsule more compliant in the external rotation direction to allow more normal angle of progression for these children. Making these activities a game that the parents participate in with their children helps ensure treatment results.

    Good luck.
     
  7. Sally Smillie

    Sally Smillie Active Member

    I work full-time in paeds and so see in-toers every day. I can't say that I've seen one yet that has been tight in external rotation (ER). Less ER than IR almost always, but never 'tight'.

    If you find limited ER I would be getting their hips XR immediately and refer a paediatric orthopaedic opinion to rule out dislocated hips. Limited ER / hip abduction (in hip extension or flexion) is a BIG red flag. I've picked up discloated hips this way in an otherwise normal 6yo, and that was the only clinical sign she had of any problems. She was in surgery 4 days later. You don't want to miss that. And as pods we should know this, it falls in our remit.

    This is how I would assess:
    History: worse when tired? (indicates weak glut med especially), always present since began walking or developed more recently, family history, sleeping and sitting positions (worst offenders that must be stopped are sleeping on tummy, bottom in air, W sitting or kneeling on feet)

    Examination
    1) Hip assessment (IR/ER in hip flexion and extension, abduction (flexed/extended), gluteus medius strength (eg. clam ala core stability) looking at range, endurance and control)
    2) Ham length (overall, medial and lateral)
    3) Knee assessment (inc. IR/ER, hyperextension)
    4) Foot (metatarsus adductus? flexible or rigid, peroneal strength/activity)
    5) Femur and tibia for any rotation
    6) and of course gait (walking and running). Do lots of laps to induce fatigue and see what effect that has. Then see if they can walk straight on demand
    Am bound to have forgotten something, so apologies in advance

    It is not unusual in young children (under 7) to have hip IR/ER of 90 degrees, amongst the in-toers you may find the same overall range, but assymmterical distributed eg. 110 degrees IR / 80 ER. Especially is they sit W as Kevin mentions above. Kneeling on feet is also a problem as it encourages and allows excessive genicular rotation to persist.

    Your treatment must follow your assessment as Craig rightly mentions. No point in stretches if you dont find something tight, although bear in mind it would be highly suspicious to find anything tight other than hams in these children. So too, strengthen that which is weak (if implicated in the resultant gait)

    In addtion to earlier posters who mention tight medial hams (which is quite correct), also remember that with weak glut med you almost always get a weak VMO. This often manifests in gait with poor femoral control and femur may also cross mid-line. Re-training and stretngthenig if both are necessary to correct this. In older children who presistantly in-toe, gait re-training may be re-quired after strengthening and stretching. In-toers very often have poor core stability which should be addressed (and is part of the reason why they get tight hams in an otherwise hypremobile body - as they brace with their hams to gain some stability) Pretty typical picture really.

    Hope this helps,
    Sally
     
  8. Sally Smillie

    Sally Smillie Active Member

    Oops, failed to mention that weak glut med/VMO will manifest in excessive IR of patellae in gait too, not necessarily just femur crossing midline.

    As for strengthening them, that is age dependant. In children below 6-ish the activities Keven describes are the
    best course of action. Also try as ballet, frog jumping, duck walking. The latter two especially helpful for the in-toe of genicular origin

    Older children definatley clam's and VMO strengthening (VMO wall slides good as easy to do, hard to get wrong and v effective) plus gait re-training. Hardly needs mentioning but the instrinsic motivation to change essential to alter the habitual side once adequate strength is acheived. We can take the horse to water, but can't make it drink

    Sally
     
  9. Timm

    Timm Active Member

    Hi Sally & Co,
    Thanks for the valuable information, but Sally could you please elaborate on how VMO wall slides are performed?
    Regards, Tim
     
  10. Sally Smillie

    Sally Smillie Active Member

    VMO wall slides•Stand with bottom, shoulders and head touching wall
    •Feet shoulder-width apart, pointing straight ahead and out from the wall so that at lowest position hips and knees are at 90 degrees
    •Gently squeeze a ball/cushion between your knees
    •Slide down the wall, never lower than the picture (ie thighs horizontal)
    •Then gently slide back up to start position

    Goal: Do 1 more everyday than you did the day before, gradually working up to 35

    Tips:
    • If they 'snake' up the wall, encourage them to do it in front of a mirror so they have the visual feedback to try to go straighter. This usually is enough to sort out the muscular imbalance.
    • Parents can put a mark on the floor for the foot position so they don't have to think about it every time
    • Choose the right sized ball so that we get a squeeze (isometric contraction) but maintain knees at shoulder width apart
    • I do a deal with the kids, I'll give them the weekend off if they work on these monday to friday, I also give them public holidays off and time off if they go away on hols. It never gets done on hols anyway and giving that permission maintains motivation.
    I'll send the graphic tommorrow.
    I get fantastic compliance, BUT in order to acheive this:
    • I demonstrate it
    • get the child to practice it under your coaching and
    • provide an illustrated exercise sheet with full instructions to take home.

    Cheers,
    Sally
     
  11. RobinP

    RobinP Well-Known Member

    Does anyone look at femoral neck angulation and femoral torsion as a way of determining if the intoeing is an osseous issue as opposed to just external rotation/internal rotation ratio?

    Billi Cusick who looks into a lot of transverse plane abnomalities in children with neuromotor dysfunction did this paper to look at assessment procedures. I can only access the abstract

    http://physicaltherapyonline.org/cgi/content/abstract/72/1/3

    but someone might have the full paper? I think it is quite informative.

    There is also a critical distinction between femoral antetorsion and femoral anteversion

    http://moon.ouhsc.edu/dthompso/namics/interact.htm

    Ryder's sign being the method for determination of femoral antetorsion described by Cusick and Stuberg, 1992 - http://moon.ouhsc.edu/dthompso/namics/antevert.htm

    Sally,

    Great description of assessment and treatment plan for intoeing gait - quite a few things in there to be adding to my repetoire - thanks

    Robin
     
  12. Rich Blake

    Rich Blake Active Member

  13. musmed

    musmed Active Member

    Dear All
    Buy why are the hamstrings short in the first place?
    Regards
    musmed
     
  14. Sally Smillie

    Sally Smillie Active Member

    Please find attached an excerpt from my exercise sheet with groovy diagrams. I'm happy for you to use it but ask that you credit the source. I have made the diagrams myself based on screen beans, using a screen bean head. The rest has been drawn by me. I hope this is helpful.

    View attachment Exercise program_INTOE exercises.doc
     

    Attached Files:

  15. pebbles

    pebbles Member

    Paul,

    I am going to take up the challenge!

    A weak glut max could cause the hamstrings to overcompensate and shorten. Glut max also adds in lateral rotation so it would fit with in-toeing gait.

    Also a posterior pelvic tilt would cause hamstrings to shorten. I am not sure how this would cause intoeing though?

    What are your thoughts?

    Patrick









    Patrick
     
  16. musmed

    musmed Active Member

    Dear Patrick

    I posed the question simply because everyone has an answer on how to treat but not why.
    So I commend on you for thinking about it.

    The great Vladamir Yanda used to ponder over this problem.

    In simple terms the quads are 5 units strong.
    the hams are 3
    gluts 2
    third law of motion.

    In sprinters they can fire the hams and gluts together and thus awesome power.
    middle distance runners usually have the hamstring followed by the glut and then the erector spinae in set patterns.

    Now any of these patterns can be dysfunctional. The commonest is no glut firing at all and this is common in children too.

    It is so easy to test.
    1. lie them prone
    2.place a finger on hammy and thumb of glut max
    3. explain that when you yell (i mean yell) fire they have to elevate a straight leg from the bed.
    You will soon see what is happening to the sequence.
    The role of the erector spinae is to initially fire on the same side and then progressively swap sides by the thorico lumbar junction.
    When dysfunction occurs here many a strange happening occurs. Very often the trapezius becomes involved and often will elevate the neck and turn the head.

    Now I mentioned turning the head. I must think that there is a reason for this and I looked from the top down and this is where I found the atlanto-occipital joint involved.

    Once this is corrected the abnormal erector spinae/trapezius problem disappears.

    So back to intoeing. I agree with your proposition that weak gluteus maximus will give the picture you give along with a posterior pelvis tilt will do the same.
    Now another dilemma
    was the posterior pelvic tilt caused by the:
    1. posteriorly rotated innominate on that side
    2. acting weakly quads that is inhibited not fatigued
    3. short psoas muscle on that side
    4. hypertonicity of the postural muscles ie. hamstring
    5. any of the above
    6. all of the above
    7. other factors. eg. talus mobility, atlanto occipital joint problems.

    Hopes this keeps you thinking.
    To me the answer is anything in the skeletal system can be a cause.
    Who is to say that intoeing is a symptom of something else not the problem itself?

    Regards from a wet south coast.
    Places 200miles from here have water running on them for the first time since 1970!
    Regards
    Paul Conneely
    musmed
    PS running a workshop in Dunedin NZ in december if anyone interested.
    www.musmed.com.au
     
  17. pebbles

    pebbles Member

    Paul,

    Co-incidentally last week I went to a chiro for neck pain and he found I had bilateral inhibited glut max. Muscle function was restored with correction of my neck...I think it was C5 or C3. It was pretty cool.

    What's your workshop topic?

    Patrick
     
  18. musmed

    musmed Active Member

    Dear PAtrick
    Cyrius Crane 111 school of chiropractic used to talk about the eternal triangle.
    The OA joint- TMj- and SAcro iliac joint. I make it a quadrella by adding the talus.
    Something out in one can appear as a problem in the other.
    Just proves we are a unit of 'one' and have to be addressed as such.
    the topic is the biomechanics of the foot and ankle in its relationship to the 'one' and how to mobilise/manipulate/and use Jones' strain counterstrain.
    Thank you for asking.
    It's all on the website, by tomorrow.Hope you can come
    Regards
    Paul Conneely
    www.musmed.com.au
     
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