ppv vs "rotational issues"

[rom3o]

How do you discern between a pes planovalgus deformity and "rotational" issues? Let me give you an example:

I had a kid in the other day for a pair of FOs (this was his 5 week f/u), feet looked as if they were equally flat, etc upon initial eval. After I had him walk around again his right foot was really externally rotated (what I thought was typical of severe ppv), and he was stubbing it on the floor every so often too -- the mother says he will trip occasionally.

I tried medially posting the rt FO some and it really did not look any better... the only thing I could think of was that perhaps it was a "rotational" issue with the bones as I mentioned earlier (external tibial torsion???) -- wasn't entirely sure but I told the mother to mention it to the doctor next time they went.

Are there any tests (muscle-strength wise, everything seemed normal) that I'm not familiar with that could help you decide this? Something to look for?

Thanks

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[streetsweeper]

How do you discern between a pes planovalgus deformity and "rotational" issues? Let me give you an example:

I had a kid in the other day for a pair of FOs (this was his 5 week f/u), feet looked as if they were equally flat, etc upon initial eval. After I had him walk around again his right foot was really externally rotated (what I thought was typical of severe ppv), and he was stubbing it on the floor every so often too -- the mother says he will trip occasionally.

I tried medially posting the rt FO some and it really did not look any better... the only thing I could think of was that perhaps it was a "rotational" issue with the bones as I mentioned earlier (external tibial torsion???) -- wasn't entirely sure but I told the mother to mention it to the doctor next time they went.

Are there any tests (muscle-strength wise, everything seemed normal) that I'm not familiar with that could help you decide this? Something to look for?

Thanks

Did you do a full bio eval?

I think you can easily tell if the patient has a "rotational" problem by having patient lie supine and observing the position of the feet/legs.

All of these should be noted while pt is lying supine:
-How much was hip rotation, externally vs internally b/l??
-What is the patient's knee position? varum/valgum?
-What were the malleolar position angles? (same thing as tibial torsion angles). RI: 15-18 degrees
-Did you test the Posterior tibialis muscle strength? push against the plantar medial 1st met head and have patient push against your hand...then use the other hand to palpate the tendon to test tension and integrity. (r/o PTTD)

When patient is standing up, what is the angle and base of gait? Tibial position? RCSP vs NCSP?

During gait:
Patellar position (internal or external)? Any hip drop?


Also, were any xr taken? (r/o any osseous deformity i.e., tarsal coalitions)

Good luck.

 

[rom3o]

Thanks for the response. I am neither a pod student nor a DPM so my knowledge and what I have access to is very limited (which is why I look forward to becoming a DPM).

I am familiar with most of the terms tests you referred to (although the only pttd test I ever knew of was basically just have the pt stand on their toes) but it would really be out of my way to try and do all of that -- which is why I just referred the patient back to the doctor if the mother was really concerned about it.

I guess I was looking for a quick and easy way thanks though, I am now better informed.

 

[streetsweeper]

My bad yo. But that's impressive that you are familiar with all of that. I only posted a bunch of pertinent examples of biomechanical tests you can do to determine "rotational" deformity. The full biomechanical eval is pretty long but must be done within 15-20 minutes if you want to survive in private practice (at least that's what we were taught). IMO, biomechanics is pretty fun.

As for the PTTD tests, you will learn in pod school that each attending has their own way of doing thangs. So you guys test it by standing tip toe? How is that possible? B/c IMO, standing on toes doesn't sound like it'll do any good....you have the gastroc/soleus muscles to accomplish plantarflexion thus, tip toeing. If the pt is lying supine, you can "isolate" the Posterior Tibialis firing by not only plantarflexing but also supinating and adducting the foot at the same time. Unless you can prove me wrong. Just my thoughts.

 

[krabmas]

Thanks for the response. I am neither a pod student nor a DPM so my knowledge and what I have access to is very limited (which is why I look forward to becoming a DPM).

I am familiar with most of the terms tests you referred to (although the only pttd test I ever knew of was basically just have the pt stand on their toes) but it would really be out of my way to try and do all of that -- which is why I just referred the patient back to the doctor if the mother was really concerned about it.

I guess I was looking for a quick and easy way thanks though, I am now better informed.

I think you did the right thing by referring the patient back to the Doc.

 

[rom3o]

Thanks. Krabmas, I just read that you're completing your residency at INOVA. Who knows, maybe I've gotten some referrals from you or some of the docs you work closely with -- I'm right around the corner from you.