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Metatarsus Adductus, 2009 - the year of the comeback

Discussion in 'Pediatrics' started by Bug, Mar 26, 2009.

  1. Bug

    Bug Well-Known Member


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    Just wondering for those that see a few babies, have you noticed an increase? While babies are getting slightly larger on average, this appears disproportionate. With no specific ethnicity/gender as the predominate.

    There appears to have been a decline in the early 2000's. Even the literature makes note of it not appearing as frequently however late last year to this year it is everywhere. On x-ray there is defiantly 20-30 degree adductus, often with varus) bowing/hooking of the metatarsus.

    Is anyone else noticing this or am I just working in the area of banana feet. Other than casting, which we often do, what else is there? The literature is all from the 90's and that is generally what we are being guided by. Any thoughts?
     
  2. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    ? larger babies = less intrauterine space = tighter limb folding = more MT adducutus.

    Certainly something to try and look into if you're attached to a mother's/maternity/children's hospital....

    Interesting observation Cylie, or is it an artifact of your environment and referral patterns?

    LL
     
  3. Admin2

    Admin2 Administrator Staff Member

  4. MelbPod

    MelbPod Active Member

    What a coincidence! I just had a little girl in this morning that I need a bit of advice with:

    Pt History:
    4y.o female.
    At birth there was "concern over hip development in future", but no hip dysplsia. Mother was told to monitor?
    Walking at 14 months
    Intoeing has been a concern since walking began. Reported clumsiness and falls more oftewn than peers.
    X-Rays show no osseus deformity of hips or pelvis.


    Chiro opinion: Pelvic imbalance

    Orthopaed opinion: Advised on sitting sleeping positions. Discouraging W-sitting.
    Advised on stretching and massage for the hips and feet. Surgery not warranted.

    My Assessments:

    - Tightness of hip abductors
    - Knee position normal, no tibial torsion.
    - Flexible Metatarsus Adductus of both feet
    - everted heel
    - excessive lateral loading of mid-fore foot
    - In-toeing most severe dynamically
    - footwear appropriate stiff soled 'clarks'.

    TREATMENT:
    I discussed stretching of hips and feet with mother as had already been advised, but now feel I need to provide a corrective device for the foot. There are so many contradicting ideas, it is hard to find a suitable method to follow.
    My thoughts are around supporting the mid-foot and reducing lateral load. I was planning to modify a prefab, but any suggestions are most appreciated.

    Thanks,
    Sally
     
  5. David Smith

    David Smith Well-Known Member

  6. Johnpod

    Johnpod Active Member

    Hi Bug,

    Have you considered femoral anteversion? If this is the cause of the intoeing the situation will improve naturally upto age 16 at the rate of one and a half degrees per year.


    Or the hip sockets might be set too far round the front of the pelvis? In which case the problem may be uncorrectable without surgery (bilateral osteotomy).


    If not, and no tibial torsion, then the cause of intoeing must be metatarsus adductus - Wheaton brace is interesting - must be better than serial casting. Gait plates are disappointing in treatment of MA.
     
  7. drsarbes

    drsarbes Well-Known Member

    Hi BUG:

    Trying to read between the lines here.
    What age group are you discussing? new borns/infants/toddlers?
    Who are you X-raying?

    Treatment really depends on quite a few factors, not the least of which is age.

    Steve
     
    Last edited: Mar 27, 2009
  8. Bug

    Bug Well-Known Member

    Thanks John but definitely not femoral or tibial, it's all metadductus with the curviest banana foot. I'm not a gait plate fan for any of the above.

    Steve, generally in the 3-6 month group through to 18 months. The younger they are, the more we use stretches and back slabs and less x-ray, the older group the 9-18 months, serial cast. i generally x-ray prior to casting to get a base line measurement but also to determine angles/ varus of the met's / if just the 1st. All of this will then go into consideration of treatment/casting or referral for ortho opinion.

    Often we will cast up to 18 months with good results if it is positional but will have to check out those wheaton braces. I would be concerned about the foot sliding in them though?

    LL - we are and have been considering that. Oh, for an extra 20 hours a week to do it though. I do wondering about the referral patterns though, we have a good paed/MCHN referral network so that needs to be considered however we have had that for the last 5-6 years. It is just in last 2 years it is everywhere. I saw a training video last week that noted matadductus as a soft marker for developmental hip dysplasia based on a study from the 80's. Anyone seen anything more recent?

    Just wondering if others were noticing an increase as well?

    Sally, I am wondering with a 4 year old, if it is still flexible, just keeping good straight lastest shoes and triplanar wedges and concentrate on improving the hip positions or a paed physio may be more beneficial. You may see more of an improvement in foot positioning over time without effecting the forefoot too much?
     
  9. drsarbes

    drsarbes Well-Known Member

    Cylie.... in a permanent state of confusion............... Check out the FOOT TATTOO thread, the Truth is out there!

    Increase in Metadductus. Do you have any numbers?
    If there is an increase, qualitatively you can make an argument for fetus size, but on a quantitative level I'm not sure the increase is that significant.

    Steve
     
  10. Bug

    Bug Well-Known Member

    Steve, I'm sure it is not at the bottom of ones inked foot though :D

    Nothing quantitative. All anecdotal at the moment, just wondering it anyone else had noticed an increase in what was coming through the doors.
     
  11. MelbPod

    MelbPod Active Member

    Thanks Cylie,

    Yeah my plan is to issue triplanar wedge/mild rearfoot support, and hip exercises/ stretches and monitor over time.

    This is my first Met-adductus paed and I worried if I didnt do enough for management, the deformity would become rigid.

    Though after doing some reading, it seems if it was going to become rigid, it perhaps already would have done so.

    Thanks again,

    Sally
     
  12. cpcpod

    cpcpod Member

    Cylie,
    I am interested in your thoughts on the use of night splints for met adductus. Especially their use in children over 3 years old. Do you think they are of any use and is there any evidence to support this???
     
  13. Bug

    Bug Well-Known Member

    Hi Linda,

    I have used them however I do wonder about their success due to the age of the child. However while the deformity is still flexible there is some hope of reduction. I guess though, how much is too much? I'm not sure there is good long term evidence of this. A discussion paper in 2006 by Wan in Clinics in Podiatric Medicine & Surgery talks about stretching and padding for as long as the deformity is flexible.

    I will often use in-shoe padding/eva dots with a triplanar wedge. I find it hard to get a really straight lasted shoe so find this helps. This is based on a few studies that have been published over the years. Have a number of parents that have used this religiously for 2-3 years and had good success however this was in the child that had no postural influences. I wonder how much a normal shoe would have made the same impact though. I generally don't treat a mild metadductus though, and will x-ray and get angles if I am tossing it up.

    I do tend though to concentrate on reducing sitting and sleeping postures that are maintaining the position (sitting on knees with feet under bottom and ball sleeping) and also really try to make sure that the parent understands how much of any intoe walking is foot vs tib torsion vs hip.

    Would be nice to have some long term studies though I wouldn't like to be the one that writes the ethics proposal for leaving something that we suspect causes joint changes in the long term.

    It would be great to have some data though on comparable treatment options.....anyone need a PhD subject? Would love to know others experiences instead of just the metadductus world according to cylie.
     
  14. kateparkercochrane

    kateparkercochrane Welcome New Poster

    I've recently started treating a 3yr old with metatarsus adductus. I'm considering the use of Gecko's and possible night splinting? Any thoughts? Over the last few months have been managing with stretches/altering childs bad postural habits/appropriate footwear.
     
  15. Boots n all

    Boots n all Well-Known Member

    Regardless of the brand of footwear, check the width of the midfoot of the shoe, these children tend to be quite broad at the midfoot and not a lot of footwear is.

    As they stand in their shoes look from the rear, notice if the lateral midfoot of the upper is bowing out over the sole.

    This will only add to the childs instibility and will throw the child to load the lateral midfoot even more during gait, due to the lack of support, the child may appear to walk better bare foot if this is the case.

    If you are planning to add an orthosis this may only compound the issues of lack of width and support and compromise the outcome of your treatment for the client.

    just a couple of thoughts
     
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