NORMAL VARIANTS IN CHILDREN'S ORTHOPAEDICS
FOR HEALTHCARE PROFESSIONALS
Written by Linda Walsh, Specialist Physiotherapist and supervised by Claudia Maizen, Kyle James and Manoj Ramachandran, Consultant Paediatric Orthopaedic Surgeons, 2014
Aim
This guideline aims to help healthcare professionals by clarifying presentations that are considered normal variations within a paediatric population. Parents commonly present with concerns about their child’s lower limb alignment; this document highlights when to refer for a specialist paediatric orthopaedic opinion to Barts and The London Children’s Hospital/the Royal London Hospital.
Flat feet
FOR HEALTHCARE PROFESSIONALS
Written by Linda Walsh, Specialist Physiotherapist and supervised by Claudia Maizen, Kyle James and Manoj Ramachandran, Consultant Paediatric Orthopaedic Surgeons, 2014
Aim
This guideline aims to help healthcare professionals by clarifying presentations that are considered normal variations within a paediatric population. Parents commonly present with concerns about their child’s lower limb alignment; this document highlights when to refer for a specialist paediatric orthopaedic opinion to Barts and The London Children’s Hospital/the Royal London Hospital.
Flat feet
Presentation
Most infants have flat feet
Arches usually develop between 2-8 years of age but some adults have flat feet
Flat feet are generally asymptomatic
Common presentation is hind foot valgus, forefoot in abduction and the medial longitudinal arch is flat or collapsed
Commonly seen in very flexible children
Examination
Check if there is an arch when the child is sitting i.e non weight bearing
An arch should form with Jack’s test by passively extending the hallux and heel raising i.e. get the child to rise up onto tip toes when standing
When to refer
Rigid flat feet i.e. feet that are flat in all positions. Causes include tarsal coalition and congenital vertical talus
Painful flat feet
Asymmetry
Specific tenderness
Functional difficulties, e.g. unable to walk, run, jump, etc
What we recommend
Providing the feet are painless and flexible, they require no treatment
Specific UCBL heel cup inserts (as opposed to medial arch supports) have been shown to be helpful if feet are flat and flexible but painful or if there is excessive shoe wear
Most patients with flat feet have tight calf muscles, so regular stretching exercises can also help
Further information
http://global-help.org/publications/books/help_whatparentsflatfeet.pdf
Bow legs
Most infants have flat feet
Arches usually develop between 2-8 years of age but some adults have flat feet
Flat feet are generally asymptomatic
Common presentation is hind foot valgus, forefoot in abduction and the medial longitudinal arch is flat or collapsed
Commonly seen in very flexible children
Examination
Check if there is an arch when the child is sitting i.e non weight bearing
An arch should form with Jack’s test by passively extending the hallux and heel raising i.e. get the child to rise up onto tip toes when standing
When to refer
Rigid flat feet i.e. feet that are flat in all positions. Causes include tarsal coalition and congenital vertical talus
Painful flat feet
Asymmetry
Specific tenderness
Functional difficulties, e.g. unable to walk, run, jump, etc
What we recommend
Providing the feet are painless and flexible, they require no treatment
Specific UCBL heel cup inserts (as opposed to medial arch supports) have been shown to be helpful if feet are flat and flexible but painful or if there is excessive shoe wear
Most patients with flat feet have tight calf muscles, so regular stretching exercises can also help
Further information
http://global-help.org/publications/books/help_whatparentsflatfeet.pdf
Bow legs
Presentation
Most young children have bowed legs or genu varum
It is commonly seen from birth to 18 months of age
Pathological causes include rickets and Blount’s disease
Examination
Ensure there is symmetrical bowing present
Measure the distance between the medial knee condyles - this should be less than 5 cm.
Consider Vitamin D levels
Determine patient’s height and weight percentiles - short stature is common in various syndromes
Assess in-toeing
Serial intercondylar measurements can be taken to monitor progression or resolution
When to refer
Marked asymmetry
Complaints of pain
Activity limitations
Bowing after the age of 3 years
Intercondylar separation of > 5 cms
Progressive worsening or lack of resolution as the child grows
Following trauma or infection around the knee
If the bowing is associated with skeletal deformity or abnormality
What we recommend
Bowing can appear excessive in the overweight child, encourage maintaining a normal weight
If there is a concern, serial intercondylar measurements can be taken on a 6/12 basis to monitor resolution or progression
Encourage Vitamin D supplementation as needed
Knock knees
Most young children have bowed legs or genu varum
It is commonly seen from birth to 18 months of age
Pathological causes include rickets and Blount’s disease
Examination
Ensure there is symmetrical bowing present
Measure the distance between the medial knee condyles - this should be less than 5 cm.
Consider Vitamin D levels
Determine patient’s height and weight percentiles - short stature is common in various syndromes
Assess in-toeing
Serial intercondylar measurements can be taken to monitor progression or resolution
When to refer
Marked asymmetry
Complaints of pain
Activity limitations
Bowing after the age of 3 years
Intercondylar separation of > 5 cms
Progressive worsening or lack of resolution as the child grows
Following trauma or infection around the knee
If the bowing is associated with skeletal deformity or abnormality
What we recommend
Bowing can appear excessive in the overweight child, encourage maintaining a normal weight
If there is a concern, serial intercondylar measurements can be taken on a 6/12 basis to monitor resolution or progression
Encourage Vitamin D supplementation as needed
Knock knees
Presentation
Most school aged children present with “knock-knees” or genu valgum - this should progressively straighten by the age of 10
Can be familial
Examination
Check symmetry
Determine patient’s height and weight percentiles
Measure the distance between the medial malleoli with the knees touching - this should not be greater than 8cm
Serial intermalleolar measurements can be taken on a 6 monthly basis, to monitor resolution or progression
When to refer
Asymmetrical genu valgum
If there is pain or activity limitation
Persistence of significant knock knee beyond the age of 8 years
Intermalleolar separation of > 8 cms
If the deformity is progressive
Following trauma
If the genu valgum is associated with skeletal deformity or abnormality
What we recommend
Knock knees should resolve by the age of 8, no active intervention is required
If there is a concern, serial intermalleolar measurements can be taken on a 6 monthly basis to monitor resolution or progression
In-toeing
Most school aged children present with “knock-knees” or genu valgum - this should progressively straighten by the age of 10
Can be familial
Examination
Check symmetry
Determine patient’s height and weight percentiles
Measure the distance between the medial malleoli with the knees touching - this should not be greater than 8cm
Serial intermalleolar measurements can be taken on a 6 monthly basis, to monitor resolution or progression
When to refer
Asymmetrical genu valgum
If there is pain or activity limitation
Persistence of significant knock knee beyond the age of 8 years
Intermalleolar separation of > 8 cms
If the deformity is progressive
Following trauma
If the genu valgum is associated with skeletal deformity or abnormality
What we recommend
Knock knees should resolve by the age of 8, no active intervention is required
If there is a concern, serial intermalleolar measurements can be taken on a 6 monthly basis to monitor resolution or progression
In-toeing
Presentation
Many children walk with their feet pointing inwards
The in-toeing may be coming from the hips and thighs, the tibiae or from the feet
Infants tends to be more affected by metatarsus adductus - if the foot is flexible and correctable then no treatment is required
Toddlers tend to be more affected by internal tibial torsion - 95% resolve spontaneously
School-aged children tend to be affected by femoral anteversion, increased internal hip rotation and reduced external hip rotation
Frequently seen in female children who sit in a ‘W’ position
Examination
Assess which level the rotation is coming from i.e. the hip and femur, the tibia or the foot
Gait observation - monitor the foot progression angle
Check hip range of motion and complete a rotational profile - graphs of normal ranges are available
When to refer
Asymmetry when comparing the right side to the left side
Pain and activity limitation
If in-toeing exceeds the normal ranges
Tripping and falling in the older school-aged child which is affecting participation in activities
In-toeing that is becoming progressively worse (deteriorating foot progression angle)
High tone in muscles
What we recommend
Splints and braces do not alter the natural course of in-toeing and are not recommended
In-toeing persisting into adult life does not generally lead to pain or disability
In-toeing has been found to be a mechanical advantage in some running sports
Out-toeing
Many children walk with their feet pointing inwards
The in-toeing may be coming from the hips and thighs, the tibiae or from the feet
Infants tends to be more affected by metatarsus adductus - if the foot is flexible and correctable then no treatment is required
Toddlers tend to be more affected by internal tibial torsion - 95% resolve spontaneously
School-aged children tend to be affected by femoral anteversion, increased internal hip rotation and reduced external hip rotation
Frequently seen in female children who sit in a ‘W’ position
Examination
Assess which level the rotation is coming from i.e. the hip and femur, the tibia or the foot
Gait observation - monitor the foot progression angle
Check hip range of motion and complete a rotational profile - graphs of normal ranges are available
When to refer
Asymmetry when comparing the right side to the left side
Pain and activity limitation
If in-toeing exceeds the normal ranges
Tripping and falling in the older school-aged child which is affecting participation in activities
In-toeing that is becoming progressively worse (deteriorating foot progression angle)
High tone in muscles
What we recommend
Splints and braces do not alter the natural course of in-toeing and are not recommended
In-toeing persisting into adult life does not generally lead to pain or disability
In-toeing has been found to be a mechanical advantage in some running sports
Out-toeing
Presentation
Frequently seen in children as they start to walk due to limited internal rotation of the hip
Can be associated with other developmental variants
Be aware of other potential, more serious causes e.g. SCFE (slipped capital femoral epiphysis) of the hip
Out-toeing is more common in older children, and is often associated with knock-knees and flat feet, none of which usually require any treatment.
Examination
Gait observation - foot progression angle
Hip range of motion and torsional profile: Place child lying in prone and flex the knees to 90º; check hip range of internal and external rotation, thigh foot angle and foot shape
When to refer
Progressive condition
Functional difficulties
Presence of pain
Asymmetrical deformity
What we recommend
Splints and braces do not alter the natural course of out-toeing and are not recommended
Out-toeing persisting into adult life does not generally lead to pain or disability
Curly toes
Frequently seen in children as they start to walk due to limited internal rotation of the hip
Can be associated with other developmental variants
Be aware of other potential, more serious causes e.g. SCFE (slipped capital femoral epiphysis) of the hip
Out-toeing is more common in older children, and is often associated with knock-knees and flat feet, none of which usually require any treatment.
Examination
Gait observation - foot progression angle
Hip range of motion and torsional profile: Place child lying in prone and flex the knees to 90º; check hip range of internal and external rotation, thigh foot angle and foot shape
When to refer
Progressive condition
Functional difficulties
Presence of pain
Asymmetrical deformity
What we recommend
Splints and braces do not alter the natural course of out-toeing and are not recommended
Out-toeing persisting into adult life does not generally lead to pain or disability
Curly toes
Presentation
Curly toes are usually caused by an imbalance between the flexor (bending) and extensor (straightening) tendons
Curly toes rarely need any treatment although they can be a cause for concern for parents
Sometimes clawing or gripping of the toes and the arch of the foot can be because of an underlying neurological cause that requires further investigation - treatment for these feet is very different to curly toes and depends on the diagnosis
What we recommend
Toe spacers can be bought if the toes have broken skin or pressure areas, although there is little evidence for their efficacy
Rarely, a small operation to release the tendons underneath the toe (flexor tenotomy) may be indicated, especially if the toe has not spontaneously corrected by the age of 3
Osgood-Schlatter's disease of the knee
Curly toes are usually caused by an imbalance between the flexor (bending) and extensor (straightening) tendons
Curly toes rarely need any treatment although they can be a cause for concern for parents
Sometimes clawing or gripping of the toes and the arch of the foot can be because of an underlying neurological cause that requires further investigation - treatment for these feet is very different to curly toes and depends on the diagnosis
What we recommend
Toe spacers can be bought if the toes have broken skin or pressure areas, although there is little evidence for their efficacy
Rarely, a small operation to release the tendons underneath the toe (flexor tenotomy) may be indicated, especially if the toe has not spontaneously corrected by the age of 3
Osgood-Schlatter's disease of the knee
Presentation
Pain, swelling and tenderness over the tibial tuberosity
Often associated with tightness of the quadriceps muscle group
Most common cause of knee pain in the 10-15 age group (onset in girls earlier than in boys)
Results from excessive traction on soft growth area (apophysis) of tibial tuberosity by strong patellar tendon
Often unilateral but may be bilateral
More common in children who participate in sports, particularly during time of rapid skeletal growth (in teenage years)
Examination
Pain elicited with resisted knee extension
Prominent and tender tibial tuberosity
Rule out serious conditions in the knee (such as meniscal tear, osteochondral defect, neoplasm) or in the hip (such as slipped capital femoral epiphysis)
When to refer
Symptoms not resolving despite rest
What we recommend
Tightness of the quadriceps muscles can aggravate the pain and so daily stretches can help - an eccentirc quadriceps strengthening program can help
Taking rest periods during sports can help to manage the pain
A course of anti-inflammatories and pain killers can help if the pain is in an acute phase
Sindig-Larsen-Johansson disease of the knee
Pain, swelling and tenderness over the tibial tuberosity
Often associated with tightness of the quadriceps muscle group
Most common cause of knee pain in the 10-15 age group (onset in girls earlier than in boys)
Results from excessive traction on soft growth area (apophysis) of tibial tuberosity by strong patellar tendon
Often unilateral but may be bilateral
More common in children who participate in sports, particularly during time of rapid skeletal growth (in teenage years)
Examination
Pain elicited with resisted knee extension
Prominent and tender tibial tuberosity
Rule out serious conditions in the knee (such as meniscal tear, osteochondral defect, neoplasm) or in the hip (such as slipped capital femoral epiphysis)
When to refer
Symptoms not resolving despite rest
What we recommend
Tightness of the quadriceps muscles can aggravate the pain and so daily stretches can help - an eccentirc quadriceps strengthening program can help
Taking rest periods during sports can help to manage the pain
A course of anti-inflammatories and pain killers can help if the pain is in an acute phase
Sindig-Larsen-Johansson disease of the knee
Presentation
Similar to Osgood-Schlatter's disease but the point of discomfort is the inferior pole of the patella
Not as common as Osgood Schlatter's
Management is the same as Osgood-Schlatter's
Osteochondritis dissecans of the knee
Similar to Osgood-Schlatter's disease but the point of discomfort is the inferior pole of the patella
Not as common as Osgood Schlatter's
Management is the same as Osgood-Schlatter's
Osteochondritis dissecans of the knee
Presentation
Presents in adolescence
Pain with loading of the joint, pain is relieved by rest
There may be a family history
Associated with trauma, both minor and major
Articular surface becomes avascular with possible fragmentation of bone
Most common joint affected is the knee
Examination
Wilson’s test positive
What we recommend
Management in the early stage is rest from all impact activities
Surgery may be required to remove loose bodies or to fix fragments that may be about to loosen
Anterior knee pain
Presents in adolescence
Pain with loading of the joint, pain is relieved by rest
There may be a family history
Associated with trauma, both minor and major
Articular surface becomes avascular with possible fragmentation of bone
Most common joint affected is the knee
Examination
Wilson’s test positive
What we recommend
Management in the early stage is rest from all impact activities
Surgery may be required to remove loose bodies or to fix fragments that may be about to loosen
Anterior knee pain
Presentation
Common in children and adolescents
Can be present for a number of years
Reason for the pain is not always clear - there are pain receptors in the fat pad, tendon, the patella, subchondral bone and the quadriceps retinaculum - any of these structures individually or in combination could be a cause for pain
What we recommend
There is little evidence that any treatment alters the amount or duration of the pain
A stretching and strengthening exercise program can be used; however pain can continue to be problematic
Occasionally further investigation is indicated, particularly if there are mechanical symptoms such as locking or giving way
Common in children and adolescents
Can be present for a number of years
Reason for the pain is not always clear - there are pain receptors in the fat pad, tendon, the patella, subchondral bone and the quadriceps retinaculum - any of these structures individually or in combination could be a cause for pain
What we recommend
There is little evidence that any treatment alters the amount or duration of the pain
A stretching and strengthening exercise program can be used; however pain can continue to be problematic
Occasionally further investigation is indicated, particularly if there are mechanical symptoms such as locking or giving way
