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It has been so long since I've seen one of these and not ever one like this. Any suggestions for interventions very welcome.

Presenting problem: painful in closed F/W, "will it get worse/how to prevent it?"

Examination:
12yo girl with massive ROM whole lower limb. 5th met ROM in sagital plane about 4cm total.
Hypermobile everywhere else too, especially feet and knees.
Super mild HK sub 5th MPJ.
Mild STJ pronated stance, but to be expected in such a flexible patient, very low supination resistance.

Intervention: Clearly, 1st issue is footwear. have given advice. However, it does make her already wide foot much wider. Still doesn't answer the question on how to help...

Any other ideas? Will it get worse, can I do anything to stabilise or prevent it worsening???? All responses welcome.

Cheers,
Sally

 

Hi Sally:
Not sure what some of your abbreviations stand for or what "super mild" means.

IF you'd like information on treating a 12 year old female with apparent ligamentous laxity and a Tailor's bunion....here goes.

Orthotic control for the STJ, surgical correction (if symptomatic) for the Tailor's bunion.
If a distal osteotomy is to be performed you need to wait for the epiphysis to close.

Steve

 

Thanks for reply.

For the sake of anyone who doesn't use the same abbreviations/definitions:
ROM - range of motion
super mild HK sub 5th MPJ- a very slight thickening of skin on the plantar to the 5th MPJ (metatarsal- phalangeal joint)
F/W - footwear

Apolgies for ambiguity.

 

F/W = footwear - OK.
HK = hyperkeratosis (i figured that one out) ......
.....but "super mild"?

ROM is universal.

"mild STJ pronated stance"......if this patient is lax why would you not expect more than a "mild" pronated STJ?

And why is the F/W (that's footwear) you suggested making her foot wider?

And what is the actual problem if her hyperkeratosis is "super mild" and her pronation is "mild" ?


I only assumed that the Tailor's bunion was the main concern because you chose that for the Thread title.
Are you concerned with the Tailor's bunion getting worse? Well, yes, it will get worse, to a point.

Hopefully not "super" worse! :)

Steve

 

Hi Sally,

I think we need more information to help out.
Check the family history, does any one else have the protrusion? if so well most likely she will have the same outcome in the future.
Does this girl participate in regular activity -sprints? dances? if shoe have u checked their footwear?
does she like to walk barefoot? do her shoes have padding ?
what is her rearfoot to forfoot relationship? is there a fixed forefoot valgus or varus? how much DF of the fifth met is there to PF?
HK indicates frequent pressure. could this frequent pressure be leading to irritation- bursitis? are the shoes too narrow?
is the bunion bilateral, are the symptoms bilateral? what is the pain scale? is it mild, moderate or severe? do u need an XRAY?
is the width of the feet equal?



just some thoughts to consider to help find a course of action to try.

Steve

 

Well, mild by paeds standards. I work exclusively in paeds, so the parameters of normal are different for this population. Compared to an adult it is probably quite moderate.

Not what I meant. To make it clearer, I meant that her foot is wide anyway, thus requiring wide fit F/W, it (being the bunion) makes it wider still. Thus making the width requirements even wider still and thereby mcuh harder to find in a retail sense and to satisfy a young teens idea of acceptable fashion

It isn't at all. I was just mentioning it because I knew someone would ask if I didn't. The only issue is the bunion.

Correct.

Do you think that her inherent hypermobility, particluarly that of the 5th met increases that potential?

 

No family history

No. She goes shopping with her friends. She tends to wear flat ballet pumps :craig:

She wears flip-flops in summer (thongs if you're Aussie) and her feet don't hurt. They're only a problem in winter/closed shoes. She is self concsious of the appearance as her 'kind' friends point it out to her.

Forefoot to rearfoot is neutral, however so mobile it is easily moved into any position you like.
5th met DF=PF. At least 20mm each of DF and PF

The HK is incredibly minor, I only mentioned it for completeness. If is so minor it has never been debrided and probably never needs to be.
I absolutley think the shoes are narrow. That is they only time they hurt. She reports redness and inflammation, almost definately bursitis from silly shoes. She's 12 and would bind her feet ala Chinese if her friends did.

Bilateral, one slightly larger than the other. It is currently summer here, so she hasn't had it for a while. As above, it sounds to me like bursitis from narrow F/W.

pretty much.

Thanks for your help. I used to see a few tailors bunions when i worked in genreal pod / biomechanics for mostly adults. They were always quite rigid. Not seen one ver since I've been in paeds, and never in a hypermobile foot.

My main concerns are:
Will they get worse?
other than F/W advice is there any other intervention I sould try?

Cheers,
Sally

 

Sally:
If you feel she is pronating during stance then by all mean try orthotic control. As you are aware, many tailor's bunions are inherited; some part of a "splay" type foot, some limited to the fifth Met-cuboid joint pathology in an otherwise normal foot.

If she already had a rather high IM angle (4-5th) with an otherwise normal forefoot (you haven't mentioned any other forefoot problems) then I might assume it's localized. As soon as her epiphyseal plates are closed it can be surgically correct.

Steve

 

Thanks Steve, I will get XR done and look at those and go from there.

Cheers, Sally