Would appreciate some advice/input on my 9 year old patient. I do not normally see such severe cases like this and would refer on but there are no podopaedatric specialists in Singapore. Parents brought her in last year after having noted that the left foot 'had gone out of shape over the last year'. They had previously seen an orthopaedic surgeon who recommended leaving it alone until she was fully grown after which she would need surgery. The child complained of anterior ankle pain after activity and frequent falls. She had also had lateral ankle sprains.
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She was a 'C' section birth and all milestones were normal. Her mother has a mild met adductus and her sister had a similar foot shape on the right foot but not nearly as severe.
She has general ligamentous laxity. Left foot rear foot was inverted in relaxed and neutral calcaneal stance, inverted and adducted forefoot, hyper mobile ankle and subtler joint, tight peroneals, genu recurvatum, no response to Jacks test and medial fat pad displacement at the heel.
I recommended physio and massage for the peroneals and I referred her to a paediatric orthopod and a neurologist. The Drs noted a slightly increased knee reflex on the left side and suggested a MRI of the brain. Parents were not keen to go ahead with this.
After consultation with some colleagues in UK and Australia for the left foot I gave her a 3mm poly orthotic with reduced arch fill, 0 dgr intrinsic grind, apertured heel cup, 6 dgr valgus EVA forefoot wedge extended to the sulcus. The orthotics have reduced all the pain and there have been no further ankle sprains and activity wise there are no problems.
When she came in for her review the foot has definitely progressed. I noted that she now has a habit of standing with one arm straight and the other arm hooked behind her back and round the straight arm (hope this makes sense!) which appears to be causing rotation at the pelvis and therefore causing the foot to rotate further. I have advised to stop this and again see physio to reduce the pelvic rotation.
What I would like advice on is there anything further I can add to the orthotic? The parents also asked me if a night splint of some form would help? The met adducts is reducible to some degree but not fully.
Thanks in advance.
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