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Metadductus in a toddler

Discussion in 'Pediatrics' started by scalikeet, Oct 5, 2011.

  1. scalikeet

    scalikeet Member

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    Hi , I am wondering if anyone still uses the old faithful technique of swapping shoes over to treat mild metadductus ?
    By swapping over I mean putting the left shoe on the right foot ...
    Thanks Gail
  2. Bug

    Bug Well-Known Member

    If you think of paediatric foot anatomy and how toddlers feet functions during gait, why would you even consider it?

    What is your reasons for asking?
  3. scalikeet

    scalikeet Member

    Thanks Cylie.
    I have had a 2 yr old present with mild metadductus which is causing a bit of tripping/ clumsiness . His parents had been told to swap the shoes over .. Which I might add has helped with his alignment greatly ..... I haven't heard of this technique being used for years ! I'm am reluctant to add prefabs/ orthotics / gait plate type devices at this stage. There appears to be some hip involvement but like I said it is more the metadd that's is causing the intoe appearance.
  4. Bug

    Bug Well-Known Member

    Yes, very old fashioned and if you think of the force, probably one of the reasons it caused long term damage.

    I work on the following principles:
    If we think about what is know about metadductus - we know it is associated with DDH, therefore hips need to be ++ checked.

    We know if it is flexible (correctable past the midline), it will fix itself with time. Why waste time and money trying to do something the body will do anyway.
    We know if it is rigid (unable to be corrected) it needs surgery, nothing we do will make a difference.

    Then there is semi-rigid (able to be corrected to the midline). How is a gait plate/orthotic/gait plate going to correct a forefoot transverse plane deformity? Your options are splint or cast. Both of which require skills most pod's don't have or aren't taught or don't have the back-up if things go wrong.

    Intoeing in kids is generally normal. One of the best things we can do as a profession to get with the times and realise we can't fix a lot of this with an orthotic, nor should we when the body will fix it itself.

    Can I suggest some good papers:
    Staheli, L. T., Corbett, M., Wyss, C., & King, H. (1985). Lower-extremity rotational problems in children. Normal values to guide management. The Journal of bone and joint surgery. American volume, 67(1), 39-47.

    Staheli, L. T. (1987). Rotational problems of the lower extremities. Orthop Clin North Am, 18(4), 503-512.

    Bleck, E. E. (1983). Metatarsus adductus: classification and relationship to outcomes of treatment. J Pediatr Orthop, 3(1), 2-9.
  5. scalikeet

    scalikeet Member

    sorry i shouldnt have written gait plate for correction but Im not sure if the device im thinking of actually has name . suppose it must but cant think of it right now .
    thanks for the papers and your help !
  6. ClintonAbel

    ClintonAbel Active Member

    Swapping shoes is a bad idea. Unless you stabilise the rearfoot segment you have the ability to tilt it into a valgus alignment, possibly producing a skew foot.
    Best to stabilise the calc-cuboid region and then abduct the forefoot.
  7. Sally Smillie

    Sally Smillie Active Member

    Cylie's answer has everything in it you need to know. I have nothing to add. Don't be messing with devices. The rigidity determines the course of treatment. Be conifident that your are giving th best possible advice when you advise the parent. Being seen to do something might appease the parents desire for 'something to be done' but don't give into it and give a product, esp if you gain financially from it, as all it is is a 'parent pleaser'. However tempting..
  8. scalikeet

    scalikeet Member

    I actually saw this patient again today . Ihad a look at the hips . Total rom is normal however the range of internal vs external isn't . Both sides have decreased external rotation and plus plus internal .. Dont ask me exact degrees it's too late and brain thinking about sleep ! The mother has remarkable hyper mobility knees thumbs etc .. and her son has increased mobility in knees , has huge rom in ankles ...
    I'm thinking that with the hips in this position it will affect the buttock mm to fire appropriately and hinder stability as well as causing a internal rotated tendency .
    I think I need to closely monitor at this stage . I think that some of the rotational tendencies are fairly age appropriate and may self correct .
    Any thoughts appreciated
  9. Sally Smillie

    Sally Smillie Active Member

    sounds like a rubbery family. They tend to run like that. It is worth bearing in mind (both yourself and her) that the mother was more than likely exactly the same when the same age too. If they are rubbery as you say, I am assuming that the MA is fully flexible/correctable??? If so, we review in 12 months - only if the parent is anxious. Otheriwse advise them that 95% of them get better on their own and to contact you if she's still worried by say age 5.

    It is very difficult to tell what you mean by 'decreased' ER at the hip, that is very relative and what is more, age dependant. In the under 5's, it is not unheard of(although not ideal) to have IR of 110 degrees. ER values I would commonly expect are more around the 70-90 mark. The QUALITY of the end ROM is important to bear in mind, beware of clunks, brick walls, crunching etc. If it's squidgy/loose I woudn't be so worried. If the values you mean are like that, just be looking at sitting (not in W position) and avoid sleeping on tummy. Internal genicular rotational positioning/met adductus may be worsened too by kneeling on feet.

    I AM assuming of course, that you have eliminated all the other rotational hot spots... knees, malleolar torsion and concluded it is purely met adductus...
  10. Sally Smillie

    Sally Smillie Active Member

    oops, forgot to mention if you have an IR>ER imbalance and all else is ok in the hip joint, as well as postural adivce re sleeping / sitting positions, glut med strengthehing can offer increased stability. Clamshells best. If younger and clams don't appeal, try penguin walking.

    Good luck
  11. scalikeet

    scalikeet Member

    Yes yes and yes ... Mother very rubbery , the son not so much but you can just see the trait happening there as well !
    For hips - internal rotation is huge prob more than 130 with a nice feel to end range external range was 30-40 at most with a tight end range not an osseous block but a tight - I'm not moving block !!
    The metadductus is flexible and I am not worried about it -as the swapping over of shoes has corrected that almost completely !( haven't heard this being done for hrs hence this post ) have also told family to stop this now..
    I have also advised then to do exactly the same as you have suggested .it's always nice to get confirmation that what your doing is exactly what others would do as well .

    I advised the penguin walking , not sure what clamshells are though?

    Definitely no other rotational problems it's purely hip rotation and slight metadductus ...
    Also another query .... As well as tummy sleeping he sometimes sleeps in a position on tummy but with knees tucked up ... Any suggestions on how to discourage this - I didnt have any great answers for this !!!
    Thanks for your advise Sally

    I have advised the family with exactly the same advice you have offered
  12. Bug

    Bug Well-Known Member

    Great advice there from Sally.

    As for the sleep...don't mess with it. Sure it slows down the de-rotational stuff by tucked in a ball but it decreases with age, decreases in the warmer month. Unless you want a tired grumpy toddler with a tireder grumpy parent. You don't mess with the sleep. I cringe now with some of wisdom I though I had as a younger and childless pod about sleeping postures. Now, having 2 that are non-sleepers, I would never inflict that on another parent. Don't mess with the sleep, it will stop as they grow and age.
  13. Kidsfeet

    Kidsfeet Active Member

    This is absolutely false. If it is flexible, it is more likely to become a skew/Z foot which is extremely difficult to manage long term. The more rigid variety tends to favor a more cavus foot type that becomes a poor shock absorber and cause a myriad of other issues.

    I'm sorry, but MA is not a normal phenom in children, and I've not seen ANY grow out of it. There are a variety of tibial, femoral and hip rotatory (extra pedal) phenoms that can mimic met adductus (i.e. cause the foot to have an intoed appearance), but if these are ruled out and the deformity is strictly pedal in origin, it must be evaluated and addressed. I rarely see these children young enough to address the issue with serial casting or even splinting and wish I would see them in their infancy or shortly after they become ambulatory, such that I can help with minimal intervention that they will ever remember.
  14. Bug

    Bug Well-Known Member

    Kidsfeet, I work in a team that just sees under 6's. I would see a great deal of this and I dare say if you are operating and wishing you caught it earlier, you are getting the non-treated semi-flexible or rigid that we also wish we had seen earlier.

    There is a nice study that followed these kids for a while that showed most had a normal foot by the age of 6 and this was dependent on the flexibility. Clinically, after 15 years with the kids, if I am worried I monitor or splint but the flexible ones I find, the body corrects itself. Just like positional talipes, the body is a clever thing. It is the semi-flexible ones though that I advocate intervention due to future of the foot structure.

    Is it possible you haven't seen any grow out of it because you don't get them in that young? With 1 in 100 babies born with it, it is a fairly common phenomenon I would think.
  15. Kidsfeet

    Kidsfeet Active Member

    How many of these children are you following into adulthood to see the sequalae of non treatment?

    I would like to read this study if you can provide a citation. Thanks.
  16. Bug

    Bug Well-Known Member


    1. Farsetti P, Weinstein SL, Ponseti IV. The long-term functional and radiographic outcomes of untreated and non-operatively treated metatarsus adductus. J Bone Joint Surg Am. Feb 1994;76(2):257-265

    This article also references a number of other longitudinal studies.
  17. Kidsfeet

    Kidsfeet Active Member

    Interesting study. In my short 10 year career I have not been able to reproduce those results, as I have treated many who should have "grown out of it" and didn't.

    Seeing as how the study is almost 20 years old perhaps the international community should band together and do a global long term study for this.

    I also assume that I wouldn't see the ones that grew out of it. Unfortunately, the ones that I tend to see should have been treated but weren't and now are faced with difficult choices as far as how to properly address their deformities and their pain.

    I also have a hard time telling a parent to just wait and see. 45 feet included in that study isn't enough to convince me to sit back and see how things go. That's not why they come to me. They come to me since they've already heard that and know that I won't feed them that line.

    Maybe I'm overly aggressive with treating these, but the parents of my patients don't think so.
  18. But then it comes back to treating the child or treating the parents desire for treatment - which is a whole different kettle of fish.
  19. Bug

    Bug Well-Known Member

    I agree the age of the study is an issue however why keep researching something that a number of researchers have come to the same conclusion.

    Did you follow through with some of the other studies:
    379 children followed for 10 years in
    Ponseti IV, Becker JR. Congenital metatarsus adductus: the results of treatment. J Bone Joint Surg Am. Jun 1966;48(4):702-711.

    245 children followed for between 1 to 7 years
    Bleck EE. Metatarsus adductus: classification and relationship to outcomes of treatment. J Pediatr Orthop. Feb 1983;3(1):2-9.

    83 children (130 feet) followed for 7 years
    Rushforth GF. The natural history of hooked forefoot. The Journal of bone and joint surgery. British volume. Nov 1978;60-B(4):530-532.

    Again, all pretty old but using different classifications, treatment/non treatment etc all came up with similar results. That the flexible ones in the vast majority of cases don't need treating. The semi flex have better results the younger the treatment, the rigid ones need surgery.

    Stating the obvious, I agree that the ones you are seeing didn't grow out of it, otherwise why else would you be seeing them. Just like the ones that did grow out of metadductus, you wouldn't be seeing because...there isn't anything to see.

    Therefore, based on what we know, they were never going to grow out of it anyway and should of had treatment as an infant. BUT, this still doesn't mean that every infant needs treatment because again, we have some large studies showing, a majority grows out of it.

    It is up to us as clinicians to be able to expertly assess the foot and make the accurate determination to make the decision to treat the foot that needs treatment and leave alone the one that we know is ok. Treating a parent and child with reassurance is still treating them.
  20. bmulder77

    bmulder77 Welcome New Poster

    In most cases the metatarsus adductus will correct itself before the age of four. In this case treatment isn't necessary. I've found this information in a Orthopedic book which I used during my study.
    I couldn't find any information about the swapping trick.
  21. Kidsfeet

    Kidsfeet Active Member

    I just don't see this. Are you basing this off the study that was done or is this your experience? If it is indeed your experience, you should publish your data. I'm sure a lot of people would be very interested.
  22. Sally Smillie

    Sally Smillie Active Member

    Experience is not data, nor is it evidence.

    Evidence beats expereince every time. If you think you see something different, read all the available evidence, find the gaps, design a robust study, apply for ethics and run a good trial.... That is how we build a body of knowledge. It can't be beaten.

    By the way, I am a clinician through and through, not an academic before any assumptions are made. But evidence based practice, as far as we can, is the bedrock for all clinicians
  23. Bug

    Bug Well-Known Member

    Have you not read the thread? Plenty of studies quoted here looking at large numbers of children and outcomes.
  24. Sally Smillie

    Sally Smillie Active Member

    Did you mean me Cylie? If so, I have, I was just commenting on Kidsfeet professional experience not matching up at all with the body of evidence and how one might respond that. Apologies if wires crossed
  25. Bug

    Bug Well-Known Member

    Oh, sorry, there was a post in between asking for the evidence. Appears to be deleted...hmmm!!!
    I know YOU have :)
  26. admin

    admin Administrator Staff Member

    Its was a spammer. They posted a number of useless one liners in a number of threads. They got deleted.
  27. Bug

    Bug Well-Known Member

    Phew, thanks. I know my head plays tricks on me sometimes but I swore there was something there.
  28. Peter1234

    Peter1234 Active Member

    Hi guys great thread,

    can someone confirm that you actually are supposed to swap the shoes over, and does that apply to a child that is just about to start walking?

    The other question is, with a semi rigid foot ie corrects to the midline, should i refer to a pediatric podiatrist or other type of orthopedic specialist?
  29. Bug

    Bug Well-Known Member

    Please don't do this, the pressure is applied in the wrong places and could damage the foot structure.

    Yes, paediatric podiatrist or ortho is appropriate for management and correction. They may use splinting, casting or shoe padding depending on their experience and/or presentation.
  30. Craig Payne

    Craig Payne Moderator

    YES! Don't do it.

    .....Aren't you on holiday? (I can tell from your IP that you still in Bali :santa: )
  31. Bug

    Bug Well-Known Member

    LOL, yes Craig, just sitting by the pool and checked my email and saw this reply and left it, got twitchy and had to say something.........yeah you know how it is.
  32. Peter1234

    Peter1234 Active Member

  33. Craig Payne

    Craig Payne Moderator

  34. Peter1234

    Peter1234 Active Member

    Thanks for the article,

    so it seems that only the rigid met adductus should be treated, as even the semi rigid met adductus is likely to correct itself
  35. bartypb

    bartypb Active Member

    Hi Guys great thread, entering a little late as I have just started looking for outcome measures and papers on Met adductus myself. I work in a joint clinic with Physio's doing paeds in the NHS and we have had a raft of referrals for met adductus conditions. The discusions we seem to be having are similar to the thread really, but we can't seem to decide on which treatment protocols to implement. We have no one to refer to for serial casting, and surgical appliances only supply bebax boots. I have a 3yr old patient with Noonan's Syndrome who has what I would call a mainly flexible met adductus ( difficult kid to assess as goes mad when you go near his feet and is always tensed up and pushing against you) he has been screened for hips etc and it does just seem to be pedal. He came in today with the forefoot of both trainers adducted ie stretched into that position, we agree that the met adductus is at its worse when dynamic (standing/walking) and mum reports that he is started to intoe and trip. We cannot decide on wherther to leave or treat. I am for treating with splinting/bebax boots at night but the argument is will this help dynamically?

    my view on it ( and this is only a view) Dynamically the soft tissue may well contract into the adducted position over time. I would appreciate imput from all as I find this condition more and more interesting the more I read into it.



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