Ways to treat Outtoeing/Intoeing problems

[cool_vkb]

Just wondering what are the different conservative options available for a podiatrist to treat Outtoeing/Intoeing of feet related to abnormal Transervse hip neutral position ?

According to my understanding Functional orthosis can fix varus/valgus or PF 1st ray,etc or other sagital or frontal plane deformities. but how do you fix a Transverse plane deformity. i was thinking it has to be some kind of device or taping which will push/pull the feet back from its abductory position or adductory position to neutral position.

And if one runs out of conservative options. then surgically being a podiatrist our scope is to lower tib and fib (majority of states). What can be done to treat these intoeing/outtoeing problems surgically if they are arising due to tibial torsion or hip abnormalities?

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[jonwill]

It really depends on the age. I'm currently on a pediatric orthopedic team at a childrens hospital where I see a lot of this. With femoral anteversion and internal tibial torsion, we usually just tell the parent that it will resolve with age. With external tibial torsion, it will get worse with age and is usually an indication for a rotational tibial osteotomy at some point. And of course, if these things don't correct with age and really affect the patient's gate, rotational osteotomies depending on the area of deformity are always an option.

Biomechanics (especially in our specialty) are very subjective. I remember an article published years ago where they took a bunch of different podiatrists that each measured different biomechanical angles on the same patients. They all came up with different numbers and I think that says a lot. I've often called biomechanics a DPM's OMM! Don't get me wrong, they can and do serve a purpose. You don't want to fix a calcaneus and leave it in varus and you don't want to fuse an ankle in plantarflexion. But the bottom line is that if it is symptomatic, treat it. Otherwise, leave it alone.

 

[cool_vkb]

It really depends on the age. I'm currently on a pediatric orthopedic team at a childrens hospital where I see a lot of this. With femoral anteversion and internal tibial torsion, we usually just tell the parent that it will resolve with age. With external tibial torsion, it will get worse with age and is usually an indication for a rotational tibial osteotomy at some point. And of course, if these things don't correct with age and really affect the patient's gate, rotational osteotomies depending on the area of deformity are always an option.

Biomechanics (especially in our specialty) are very subjective. I remember an article published years ago where they took a bunch of different podiatrists that each measured different biomechanical angles on the same patients. They all came up with different numbers and I think that says a lot. I've often called biomechanics a DPM's OMM! Don't get me wrong, they can and do serve a purpose. You don't want to fix a calcaneus and leave it in varus and you don't want to fuse an ankle in plantarflexion. But the bottom line is that if it is symptomatic, treat it. Otherwise, leave it alone.

Are these osteotomies are within our scope? Or we refer them to orthos.

I mean ofcourse if its femoral torsion v can't go up and fix it. But can v do anything surgical in distal extremity tat can fix it.

 

[PADPM]

Yes, I know some DPM's that perform tibial osteotomies, but as you stated, the level of the deformity must be determined.

I also agree 100% with jonwill regarding the apparent subjectivity and lack of standardization regarding biomechanical measurements.

I know of many well respected university based pediatric orthopedists that rarely intervene for most of these deformities except in the most severe cases, since it's believed that the majority will resolve.

In patients that I evaluate that have excessive internal rotation with limited external rotation coming from the hip, and I believe it may be from tight soft tissue structures, etc., I recommend that the patients purchase a product such as a "big wheel" which forces the child to sit with the legs slightly higher that the rear and with the legs/hips externally rotated in order for the child to pedal the "big wheel". With continued use of this device, I've seen the tight structures loosen up and the child gain significant increased external rotation/abduction at the hip.