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Hello, I am writing my first post as I have an interesting case of a unilateral unstable left foot in a 5 1/2 yr old girl.
Her inital presentation was for what mum says " walking funny" and her chiropractor also recommended she come to me.
Her file is huge so forgive me if I leave some things out. The following is a summary the things I believe are inportant.
She walks with a limp on the left side/leg which gets worse with prolonged activity and/or tiredness. Her left foot contact is more like lateral foot contact and is supinated thru-out ie. there is minimal ground contact with the 1st ray. It is difficult to explain via words but it looks like the excess supination is coming from the hip.
I suspected Perthes or slipped epiphysis but this was ruled out on x ray. I checked neurological, reflexes are present at the ankle but not at the knee. She can stand on 1 leg (left was weak and unstable), toe to heel walk, skip, hop (but not as well and weaker on left), walk with eyes closed and jog.
Muscles are tight in hamstrings, gastroc/soleus, hip flexors and she is sore at Quad. Lumborum, glut med., piriformis and ITB trigger points.
She had an MRI because I was concerned about spinal dysraphsim and the cavus foot deformity. Report via paediatric neurologist was bulging disc L4L5 and dehydrated discs in the sacrum. No treatment was recommended here other than further MRI approx. 12 months time. She was allowed to continue treatment with me to improve core strength, posture and to stabilise foot function.
Mum is still concerned as " She is only 5 yrs old!"
Paediatrician says its because of her ligamentous laxity, which she does have, specifically lumbar lordosis but I want to be sure. To me her pelvic x rays don't look right. In A/P wt bearing view, pelvis looks skewed and higher on left with what looks like rotation through the SI joints(more space between L side joint). Is this just muscular?
Does anyone have any ideas? I haven't x rayed for a tarsal coalition, am I overlooking the obvious?
She is a lovely little girl with a great personality and is very clever. Her mum trusts me and has asked me to look into it for her.
Thanks for reading.

 

I believe she needs to see another neurologist. I would put it in the too hard basket, personally, and handball. I'm sorry I am no help to you, I am posting this more so I am notified of other responses. Great work with your assessment, very thorough! One question, has she presented with this foot type since walking, or has it recently occurred?

 

I can't answer your question exactly but from what I can recall I think she has always had some level of instability because mum said she tripped and fell alot.
I do know all normal milestones were reached but mum says she didn't crawl much. The only other thing was that she had a fall 2 yrs ago and was treated by a chiropractor for a right hip issue?(don't know details) but apparently ressponded well.
She is quite overweight, and we are trying to address this issue with diet, swimming and walking for exercise.
We live in Traralgon, Vic, so access to health services are somewhat limited locally. Suggestions for neurology referral would be appreciated.
Thanks.

 

Consider pathology to the sciatic or peroneal nerve on the affected side::

Bassett, G.S., Monforte-Munoz, H., Mitchell, W.G. & Rowland, J.M. Cavus deformity of the foot secondary to a neuromuscular choristoma (hamartoma) of the sciatic nerve. A case report. Journal of Bone & Joint Surgery - American Volume 79, 1398-401 (1997).

DeLuca, P.A. & Banta, J.V. Pes cavovarus as a late consequence of peroneus longus tendon laceration. Journal of Pediatric Orthopedics. 5, 582-3 (1985).

Schwend, R.M. & Drennan, J.C. Cavus foot deformity in children. Journal of the American Academy of Orthopaedic Surgeons. 11, 201-11 (2003).

Regards
Josh

Joshua Burns Ph.D. | Associate Professor
Faculty of Health Sciences | The University of Sydney
Institute for Neuroscience & Muscle Research | The Children's Hospital at Westmead
Locked Bag 4001 Westmead NSW 2145 Australia | e: joshuab2@chw.edu.au

 

Thankyou Josh. I was hoping you would read my post having heard you at last years Pod Conference.
Kellie

 

Kellie here some reading for you 1 of the Paper that Josh suggested, 1 written by him and another 1 about pes cavus

hope it helps

 

Thankyou Michael

 

Kellie,
You could also just bite the bullet and refer them to Monash Children's. I know it is a fair hike for them however it is your best bet it will be looked into. They are the closed Children's hospital to you.
They will obviously accept the GP's referral or you can refer her in. If you think the parents would, message me and I"ll give you the details.

 

Cylie, I am seeing her in a week or so and I'd like the details re. childrens hospital. I am sure her mum would take her if I recommended it so thanks.
Kellie