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12 yrs old boy brought to my OPD c/o of
walking on his lateral aspect of foot 6 days duration.
no trauma/ fever
o/e foot appears normal no swelling .
tenderness of the lateral joint line of ankle joint.

he is walking with foot and ankle in supination.

x rays-. compared with normal side i noticed increaed subtalar joint space
is it normal.
what is the cause of this gait.

how to proceed with this patient?

suresh

 

Re: wakling with supinated foot

is it due to severs disease?

 

Re: wakling with supinated foot

Suresh:

The opening of the sinus tarsi on the lateral view is one of the radiographic landmarks of a supinated subtalar joint. On the other hand, when the lateral process of the talus is seen to be contacting the floor of the sinus tarsi of the calcaneus, occluding the sinus tarsi, then this indicates that the subtalar joint is maximally pronated (Kirby KA: Rotational equilibrium across the subtalar joint axis. JAPMA, 79: 1-14, 1989).

http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=1580&highlight=Kirby sign

One possibility is that the boy has developed a supination spasm of this posterior tibial or anterior tibial muscle due to some form of pathology within the subtalar or midtarsal joint. If a supination spasm is found, then you may try putting him into a brace or BK cast for 2-4 weeks to see how he responds. An MRI scan may be in order to rule out some form of occult trauma or developing tarsal coalition.

Hope this helps.

 

Re: wakling with supinated foot

Hi Suresh,

Have you considered the possibility of Slipped Capital Femoral Epiphysis?
Or Legg-Calve-Perthes Disease?

This can sometimes result in a LLD and altered gait. Does the Pt have any symptoms/pain in the hip?

Frog leg X-ray views of the hip may be helpful if you suspect the above.

Just a suggestion.

Cheers,

FD

 

The normal foot (on the right?) is quite pronated, with a low calcaneal inclination angle, anterior break in the Cyma line, and an obliterated sinus tarsi.

The left foot is taken at a different angle, so it's a bit unclear, but the posterior portion of the tibial joint surface doesn't look right. It looks a bit raggedy, like an osteochondrosis.

Perhaps another xray or a scan would help.

Cheers

Frederick

 

I agree with Kevin that the left picture is that of a foot, with normal anatomy, in a more supinated position. When the STJ supinates there is external rotation of the leg and that would be the reason that the fibula looks more posterior in the left picture. So, there might not have been a different angle in the picture.

Did you ask the patient why they walk like that? Does the 1st MPJ hurt?

Cheers,

Eric

 

Clinically the patient walks supinated and has lateral ankle joint line pain. Assuming he doesn't have any other symptoms (I'm sure you checked) perhaps we should look at the joint.

The different angle I am speaking of is regarding the ankle joint. We can't evaluate the symptomatic ankle joint because the angle of the xray doesn't give us a clear shot of the joint surfaces.

Another lateral xray, with perhaps an ankle AP and mortise views would help to evaluate the symptoms.

The sign of inverted gait certainly could be the primary problem, but a patient with ankle joint pain will often limp inverted.

It might be better to attempt to establish a primary diagnosis before applying a cast. Causalgia, etc.

Cheers

Frederick