Musculoskeletal deformities

what is the difference between version and torsion?

version: position of femoral head in frontal plane

torsion: osseous position of bone in the longitudinal axis; twist

what is ante version vs. retroversion and is it unilateral or bilateral?

ante version: in-toeing usually bilateral; more common in girls

retroversion: out-toeing, affects all ages; more common in boys, often unilateral, seen most in newborns and obese children

what is the difference between internal and external tibial torsion?

internal: in-toeing, present between 2 and 4 years; equal in boys/girls, usually bilateral

external tibial torsion: out toeing, present between 4 and 7 years equal in boys and girls, usually bilateral 

what are some subjective information we can be gathering? what position is anteversion and internal tibial torsion associated with?

birth history, age when first noticed, preferred sitting position

anteversion=W sitting

internal tibial torsion=short kneeling/prone sleeping

what is the foot progression angle?

angular difference between axis of foot and line of progression, measured in degrees

what numbers represent in-toeing vs. out toeing and what is the average?

negative= intoeing

positive=out-toeing

average: +10, range -3 to +20 degrees

mild=-5 to -10

moderate= -10 to -15

severe=greater than -15

how is tibial torsion measured? 

angular difference between longitudinal axes of thigh and foot in prone and the knee flexion at 90 degrees 

what are the measurements of internal vs. external tibial torsion?

internal: -30 degrees

external: +30 degrees

in prone what does anteversion vs. retroversion look like?

anteversion: IR > ER

retroversion: IR < ER

what is our main intervention for anteversion?

spontaneous resolution, avoid W sitting, if severe may look at derotational osteotomies, risk/benefit, patellar alignment

what is intervention for internal tibial torsion? 

natural history of improvement, orthotic treatment, strapping, surgical intervention when TFA is greater than 3 s.d.

what is the etiology of idiopathic toe walking?

don’t know exactly but toe walking is common with CP, muscular dystrophy, Charcot Marie tooth,

what does gait look like in idiopathic toe walking?

increased ankle PF during stance and swing, knee hyperextension, normal knee and hip kinematics but abnormal ankle

how does idiopathic toe walking come to be?

purely benign, does not typically carry over into adulthood, some adults who were toe walkers have decreased heel strike or a bouncing gait but few report ankle problems.

what are some functional impairments in toe walkers?

gross motor skills, gait abnormalities, ROM loss, strength limitations, especially DF’s, decreased balance

what is normal heel- toe gait pattern? 

1st rocker: heel strike and PF’s lower foot eccentrically

2nd rocker: ankle relative DF as tibia/body move forward over foot 

3rd rocker: ankle PF as gastric and soles contract concentrically 

swing: ankle DF due to contraction of tibias anterior to allow for foot clearance 

in toe walkers what are functional limitations?

1st rocker is absent

slope of the second rocker flattened

sudden ankle PF increased during the 3rd rocker and mid-swing phase

greater ankle PF force necessary for normal heel-to-toe walking than for toe walking

what is normal DF and PF ROM?

DF: 0-20 degrees with knee flexion and 0-10 degrees with knee extended

Normal: PF ROM 0-50 degrees

what does decreased ankle dorsiflexion or functional ROM impairments

can’t use skates, ski boots, can’t walk uphill, knee hyperextension, consistent ITW show decreased ankle ROM, pain after activity

what presentations will patients have with decreased ROM? 

fixed heel cord 

tight achilles tendon 

not all patients who toe walk have short achilles tendons

some children cannot squat with their heels down 

when should we treat idiopathic toe walking?

normal in children under 2

can improve without treatment

are there functional deficits

what are some conservative treatment options for idiopathic toe walking?

stretching, strengthening, HEP, orthotics, short term monitoring

what are next steps to improve ROM? 

serial casting, botox injections, surgery for gastric, coleus, achilles, aponeurosis release 

what is serial casting?

material can easily contour to the foot to address inversion, eversion, and plantar flexion

foot and ankle are held in constant stretch, leading to tissue relaxation

increased number of sarcomeres

what makes up the rear foot, mid foot, and forefoot?

rearfoot- calcareous and talus

midfoot: navicular, cuboid, cuneiforms

forefoot: metatarsals, phalanges

what movements make up supination? 

rearfoot calcanela varus 

mid foot inversion

forefoot adduction 

what movements make up pronation?

rearfoot calcanela valgus

mid foot eversion

forefoot abduction

what is subtler neutral?

most stable position of foot

evaluate foot for capacity to achieve position

cast in Subtler joint neutral

what position do you want for ankle positioning when doing serial casting? 

introduce weight bearing through the heel even if you have to use heel lifts, PT positions joint in right spot and holds during cast application 

what are primary compensations?

posterior weight shift

postural instability

imbalance of flexion/extension

sensory issues

compensatory pronation/valgus

what is the posterior weight shift caused by?

with new gained movement into dorsiflexion, patients will tend to maintain posterior shift

with toe walking what are muscle compensations that occur? 

trunk flexors are weak

anti-gravity trunk extensors are put in a position of overuse

trunk rotation is decreased in movement due to this imbalance 

what are some things we can do for sensory issues?

desensitization- brushing, rubbing with rough washcloth, rubbing with various textures

while in casts what HEP can patients do?

abdominal strengthening, quadrupled cat and camel, standing with weight shifted back on heels

impairment based interventions: hamstring, gastric and soles passive stretches, custom night splints