How thorough is your evaluation of pediatric gait? Emphasizing the value of gait assessment in fostering an accurate diagnosis and appropriate treatment, this author offers pearls and nuances in evaluating the stance and ambulation of pediatric patients.
Too often, many podiatric examinations begin with only focusing on the feet and not on assessing the body as a whole. Many podiatric physicians rely on their hands and what they see when evaluating the foot only, rather than taking a systematic approach to learning about how the malalignments in the body can contribute to foot deformities.
Examining patient gait and stance can be an invaluable aspect of diagnosing podiatric conditions. Podiatrists must take extra care when analyzing children’s gait, as pediatric patients present special concerns and can be fairly unpredictable when one attempts to assess them.
The psychosocial aspects of evaluation and management of children’s foot problems loom much larger than in the adult population. Children must feel at ease with their doctor and must be comfortable with their surroundings before one can initiate a true attempt at a concise diagnostic process.
In addition, physicians must take into account the comfort level of the pediatric patient’s parents. This has a huge impact on how the evaluation of the patient proceeds. Have a thorough discussion with the parents regarding the child’s past medical history and when the child reached growth landmarks. Also discuss the family history of disease, including issues such as a history of muscular dystrophy or Charcot-Marie-Tooth disease.
Essential Tips For Evaluating Stance
When it comes to evaluating the pediatric patient, first observe his or her natural stance position. The more comfortable children are with you, the less likely they will have a rigid, at-attention stance, which children sometimes assume when adults ask them to stand up straight. This very unnatural position can make it difficult for the podiatric physician to get a true picture of stance as it will potentially alter and exaggerate some of the natural body positions that are essential to the examination.
Effective examination of a proper stance position can show various attributes that can lead to a more concise diagnosis. This is valuable when assessing exactly where the deformity originates in the flow of shoulder, spine, hips, knee, ankle or foot segments.
Shoulder and spine position can have a profound effect on lower extremity alignment. If there is a severe kyphosis, lordosis or scoliosis, one can isolate the origin of the deformity and make the proper referrals.
Malformations or physiological progression of hip retro- or ante-version can also affect lower extremity alignment. Once again, this can help in isolating the origin of the deformity so the podiatrist can facilitate referrals with other professionals who may need to be involved in the care of this patient. For instance, a parent may complain that his or her child’s toes point out. This may result from a hip deformity rather than a foot deformity.
Evaluate the knee position while the patient is standing. Remember that there is a physiological progression of knee position in the frontal plane. Most newborns will present with a genu varum attitude but this should revert to a more straight legged presentation between the ages of 18 and 24 months.
As children age into their third year, the knees should then present with a more genu valgum appearance, finally culminating again into a more straight legged attitude between the ages of 4 and 6. In females, this is slightly skewed to the more genu valgum position due to the changes in structure to their pelvic girdle as they age to maturity. We can also view the knee in the sagittal plane for any levels of genu recurvatum. One can see this when evaluating spinal position as well since these two are intimately related. A genu recurvatum attitude can lend itself to an equinus positioning.
Evaluate foot positioning while patients are in a standing, static position. Physicians should evaluate the resting calcaneal stance position as well as the neutral calcaneal stance position. Pay close attention to the levels of flexibility of these two positions when developing a diagnostic algorithm.
Also be sure to do the “toe raise test” in order to ensure proper inversion of the calcaneus and proper functioning of the posterior tibial tendon. When there is an excessively everted resting calcaneal stance position, it may be necessary to evaluate the integrity of the subtalar joint and subsequently determine whether you are looking at a more rigid or flexible type deformity.
What To Look For When Observing Ambulation
The next step in the evaluation should be to watch the patient ambulate and if space allows, run. This is another step that many of our colleagues gloss over when doing an initial evaluation. However, this is truly the only effective way to glean exactly where in the gait cycle one needs to address the child’s deformity.
In regard to gait, consider the head and shoulder positioning. Doing this enables you to gauge proper arm swing and identify balance issues. After documenting this, proceed to evaluate the patient’s hip position and hip sway as well as any issues with improper muscular coordination within the hip structures. Hip positioning during gait may point to an extra-pedal cause of deformities in the foot or ankle such as in- or out-toeing. One can also identify “vaulting,” which would subsequently trigger a more thorough evaluation of limb length discrepancy issues.
Evaluating the neuromuscular origins of pedal abnormalities can begin during an analysis of gait. The podiatric physician may identify foot drop from a lower motor neuron defect or see a classic “scissors gait” that is associated with cerebral palsy.
Consider how the foot is functioning during gait. One may identify a “too many toes” sign when there is excessive abduction around the midtarsal joint. This can point to a more pronated foot type and issues related to the subtalar joint and flexible versus rigid pes valgo planus deformities. Early heel off can identify an equinus deformity. Ineffective propulsion off the first ray structures can identify an inability to lock the midtarsal joint and create a more flatfoot attitude.
Other Pertinent Examination Pearls
The next step involves examination of the patient while he or she is sitting. Start by examining for proper position and alignment of the hip structures. First, test internal and external rotation of the hip joint. In a young child, the ratio of internal and external rotation should approach 1 to 1 although this ratio does change as the child ages. Inequality in function of the hip rotators can lead to apparent pedal abnormalities that require more than podiatric expertise to treat.
Perform an initial examination of the limb length with the patient lying down. Commonly accepted practices include bending the knees up to evaluate limb length or using a measuring tape. However, if there is a question about how the tibial and femoral lengths are affecting the child’s gait and foot position, consult a full lower extremity radiograph (see the sidebar “What The Radiographs Can Reveal”). For our purposes, the classic description of a limb length discrepancy is a more pes plano valgus attitude in the foot of the longer limb and a more pes cavovarus attitude of the foot of the shorter limb.
When it comes to evaluating a potential equinus deformity, it is critical to make sure the subtalar joint is in neutral position and the midtarsal joint is locked when loading the foot. This will eliminate any inaccuracy due to foot position when attempting to measure the level of equinus. One should do this with the patient’s knee straight and then bent to evaluate for gastroc-soleal equinus versus strictly soleal equinus. While performing this evaluation, we can also assess for neuromuscular abnormalities via dermatome and myotome testing.
To evaluate tibial rotation, have the child sit up and hang his or her knees over the treatment chair and observe his or her patellar/tibial position. As children grow over the first 10 years, the tibia will rotate from a position of 10 degrees externally rotated to a position of 0 degrees. There is controversy in the orthopedic literature pertaining to whether external tibial rotation affects the foot in any way. The argument is that since the talus sits within the tibial plafond, any shift in the relationship will have dire effects on position and functioning of the foot. Once again, this points to some extra-pedal causes of what appear to be strictly pedal deformities.
Perform thorough testing for all intrinsic muscles within the foot as well as the individual joints within the forefoot and hindfoot. Note the relationships they have with one another. Evaluate whether these joints move freely, too freely (hence hypermobility) or not freely enough. This finding can spark a more thorough evaluation of the rigid nature of the presenting issue.
A Guide To Conservative Management
After doing a very thorough and complete evaluation of the gait and stance of our pediatric patient, the question turns to management.
When approaching management of the pediatric patient, three factors steer the treatment protocol: the patient’s age, the presence or absence of pain, and the severity of the deformity. It is up to the individual practitioner to estimate which of the three takes precedence and to what extent.
When a very young child presents with a severe deformity, many advocate the use of serial casting and bracing to attempt a permanent reduction of deformity. This technique can be very successful in reversing the deformity since it will not cause longstanding issues as the child grows and ambulates. One can best utilize serial casting and bracing when patients are still non- ambulatory as they are less likely to rebel against the treatment protocol.
One of the best examples of this is when an infant presents with a severe metatarsus adductus deformity. Left unchecked, a severe metatarsus adductus deformity can evolve into a severe skew type foot, which eventually can lead to a very unstable, difficult, flexible flatfoot type deformity in one of its iterations. Casting has been extremely effective in resolving this deformity if one initiates it early enough and with skill.
Casting can also be successful in the early treatment of talipes equinovarus. The Ponsetti method of serial casting is considered the gold standard for early treatment of this crippling deformity.
Bracing works much the same way although children can wear braces both when ambulating and when asleep. A good example of this is the Wheaton Brace for the treatment of metatarsus adductus and potentially for tibial torsion if your state scope of practice allows it.
If the child presents with symptoms and is old enough that casting and bracing would prove ineffective, one should attempt control of the foot deformity with the use of custom orthotic devices. There are many options available to the practitioner in this regard. The most effective orthotic treatment is a true custom molded device. These devices range from the very rigid to the somewhat flexible, and the patient’s level of deformity and potential tolerance to the device should dictate which device one uses.
A Review Of Factors That Affect Surgical Procedure Selection
When the aforementioned modalities fail to address the patient’s present complaint, one must consider surgical intervention. Selecting the appropriate procedure revolves around the age of the patient and severity of deformity. Particularly critical is having a detailed knowledge of the anatomy of the area and identifying the precise nature and location of the deformity.
Many discussions in the past have centered around Rootian theories of planal dominance. Even though Root’s theories have yet to be empirically proven, knowledge of the various aspects of his theories may serve to increase the surgeon’s knowledge surrounding the appropriate selection of the surgical procedure. It is beyond the scope of this article to go through the lists of the various procedures available and their indications, but a myriad of very well written texts and articles is available to those who are interested.
Evaluating the pediatric patient in both stance and ambulation is ultimately one of the key steps to arriving at an accurate diagnosis and formulating a successful treatment plan.
Dr. Raducanu is Board Certified by the American Board of Podiatric Surgery, as well as a Fellow of the American College of Foot and Ankle Surgeons. He also serves as the President and is a Fellow of the American College of Foot and Ankle Pediatrics. He is in private practice in Virginia Beach and Norfolk, Va.
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