Posted by: Indonesian Children | September 11, 2009

Treatment of In-toeing and Genu Varus in an Infant

The review of the literature will report on orthopedic development problems of the lower extremities in children and current treatment techniques, a review of vaccination protocols during infancy and the potential side-effects. The review will conclude with an explanation of Integrative Manual Therapy, assessment tools and general treatment techniques for the lower extremity.

Orthopedic development problems of the lower extremities
Christensen (2001) reported that the most common orthopedic problems in toddlers include in-toeing, genu-valgus, genu-varus, and pes planus. It was also reported that in most cases these conditions resolve spontaneously (Christenson 2001), improves without any treatment at all (American Academy of Family Physicians, 1994), improves with growth (Palastagna, Field & Soames, 1989), usually diminishes by the time the child reaches school (The Disney Encyclopedia of Children’s Health, 2001). Most reports indicate that observation is the best form of assessment and treatment for any of these conditions and that the need for further interventions should be addressed later in youth between ages 7 and 10.
In-toeing is a position where the feet are pointing inward, sometimes referred to as ‘pigeon-toed’. According to the American Academy of Family Physicians (1994) in-toeing is caused by three possible sources: metatarsus adductus, internal tibial torsion or excessive femoral anteversion. According to the Midwest Orthopedic Surgeon group (2001), the etiologic cause for these problems are familial history or positioning in the womb with the child not having enough room.
Metatarsus adductus or metatarsus varus is a curve of the foot in which the “forepart rotates outward away from the midline of the body and the heel remains straight” (Mosby, 1994, p. 987). The foot has a kidney bean shape and there is usually a crease on the inside of the foot by the arch (Midwest Orthopedic Surgeons, 2001). Metatarsus adductus is common from birth to eighteen months and in most cases is resolved without treatment. Stretching and/or special shoes is the common treatment if the condition persists, and less frequently a short series of serial casting (American Academy of Family Physicians, 1994; Midwest Orthopedic Surgeons, 2001).
Internal tibial torsion is a “medial twisting rotation of the tibia on its longitudinal axis” (Mosby, 1994, p. 1556). It is often accompanied by metatarsus adductus and occurs between 12 months to 3 years when the child begins ambulating. Midwest Orthopedic Surgeons (2001) report that in 95% of the cases the torsion is corrected without treatment. The remaining cases are treated using Dennis Browne night splints or special shoes.
Excess femoral anteversion is the inward twist of the femur. The American Academy of Family Physicians (1994) indicates that excess femoral anteversion occurs between ages 2 and 4 and is aggravated by W-sitting. They also report that braces or shoes do not help improve this condition and in most cases it resolves on its own. When not corrected, surgical intervention is performed to cut the bone and twist it outward.
Genu valgus or knock-kneed is “a deformity in which the legs are curved inward so that the knees are close together, knocking as the person walks, with the ankles widely separated” (Mosby, 1994, p. 666). Genu varus or bow-leg is “a deformity in which one or both legs are bent outward at the knee” (Mosby, 1994, p. 666). Genu varus is typically seen in infants from 12 to 18 months of age when they begin to ambulate and tend to straighten out toward the middle of the second year. Genu valgus develops during the third year and diminishes by school age. Christenson (2001) sites a 1989 study by Gould on the development of arches in toddlers 11 to 14 months up to five years of age. One finding of this study was that of 52 children, 92.3 percent of the five year olds had genu valgus.
Pes planus or flat feet “an abnormal but relatively common condition characterized by the flattening out of the arch of the foot” (Mosby, 1994, p. 1201).
Pes planus is generally present in infants at age one and development of arches occurring from that time on. Treatment may include a corrective molded firm shoe insert between the ages of two and six years.

Integrative Manual Therapy
Integrative Manual Therapy (IMT), developed by Sharon (Weiselfish) Giammatteo, PhD, PT, IMP,C, is the combination of structural and functional rehabilitation (Weiselfish-Giammatteo, 1999). Structural rehabilitation utilizes manual therapy to correct biomechanics of the spine, extremities, organs and vasculature, improve structural integrity and progresses individuals in the process of normalization. Functional rehabilitation restores optimal potential for everyday functions of the client.
IMT uses an Integrated Systems Approach (Weiselfish-Giammatteo, 1998) to address the person from a holistic view. This approach looks at all systems within the body to determine the cause-effect of the pathology presented. Integrative Diagnostics (Weiselfish-Giammatteo, 1998) is used as a tool to determine the primary cause and relationships of structural dysfunctions and impairments.
Myofascial Mapping (Weiselfish-Giammatteo, 1983) is an assessment technique to find a site of neuro-muscular dysfunction. Positive mapping over a tissue site indicates the need for intervention with manual therapy. Manual therapy treatment of the lower extremity may include, but is not limited to various Integrative Manual Therapy Techniques including Jones Strain and Counterstrain (1995) to decrease the hypertonic muscles, Advanced Strain and Counterstrain (Weiselfish-Giammatteo, 1997) to decrease hypertonicity of the vascular system, Muscle Energy and ‘Beyond’ Techniques (Weiselfish-Giammatteo, 1998) to improve the vertical dimension of the joint space, Compression Syndromes and Osseous Torsion Techniques (Weiselfish-Giammatteo, 1998) to address brain-stem protective mechanisms within the structure (Weiselfish-Giammatteo, 1998) to reveal Immune Deficiency Motility, Bone Bruise motilities as well as Disruptions of Membrane within the tissue. These motilities and a Disruption of Membrane have been defined by Weiselfish-Giammatteo (1998) and Lowen and Weiselfish-Giammatteo and Giammatteo (1997).

Procedure
Destini was evaluated and treated for two sessions with a total contact time of 4 hours. Two therapists evaluated and treated the 13-month old child using Integrative Diagnostics and Integrative Manual Therapy techniques (Weiselfish-Giammatteo, 1983).

Evaluation:
The assessment of static and dynamic postures revealed the following:
Genu varus deformities bilaterally standing/supine (pictures taken and will follow).
Toeing-in of both feet, left greater than right standing/supine (pictures taken and will follow).
Hypertonicity of the musculature of both anterior thighs, left greater than right.
Decreased joint mobility of both lower extremities.
Decreased uncompensated ranges of motion of both lower extremities (see goniometric measurements pre- and post- at end of section).
Positive Myofascial Mapping (Weiselfish-Giammatteo, 1983) over anterior legs indicating involvment of the medullary cavities of bilateral lower extremities.
Positive Myofascial Mapping of both lower extremities, especially left thigh greater than right. “Positive Myofascial Mapping indicates neuromusculoskeletal dysfunction which indicates the need for Manual Therapy” (Weiselfish-Giammatteo, 1983 p.13).
Positive recoil/tension tests for thigh compression syndromes bilaterally (Weiselfish-Giammatteo, 1998).
Subjective history was provided by Destini’s mother who indicated that the doctor wanted to apply bracing to both legs to correct the genu varus deformities. The mother also indicated that Destini receives vaccination injections in her thighs, one in the right and two in the left each time she goes to the doctor.

Treatment:
Recoil/tension tests for thigh Compression Syndromes were administered bilaterally for the following nerves: posterior femoral cutaneous nerve, tibial nerve, and common peroneal nerve. There was moderate to severe response in the recoil/tension tests for both lower extremities, left greater than right. The following techniques were administered:
Thigh Compression Syndromes.
Osseous Torsion Techniques for bilateral femurs, tibias, and fibulas.
Osseous Compression Syndromes for bilateral femurs, tibias, and fibulas.
Medullary Cavity Techniques for the right tibia and fibula.

The above techniques were developed by Sharon Weiselfish-Giammatteo, Ph.D., P.T. (1998) and are taught in the course Lower Extremity Compression Syndromes. As a result of administering the above techniques, aberrant ‘motilities’ (‘motility’ is a biologic circadian rhythm) for Immune Deficiency Motility and ‘bone bruises’ were palpated in the thighs and legs. Lowen and Weiselfish-Giammatteo defined a ‘bone bruise’ according to clinical presentation in 1997. Sharon Weiselfish-Giammatteo (1998) defined Immune Deficiency Motility. The techniques to correct these motilities were applied to the areas that presented them clinically. These techniques are presented at DCR and Therapeutic Horizon courses. The recoil/tension tests for thigh Compression Syndromes presented as mild after treatment. The pre- and post- photos also document the progress in reducing the genu varus deformities secondary to treatment.

Range of Motion Measurements
Pre-testing: Uncompensated ranges of motion before techniques to correct bilateral genu varus:
Hip flexion: Right 48 degrees; Left 30 degrees
Hip abduction: Right 35 degrees; Left 33 degrees
Hip adduction: Right minus 10 degrees; Left minus 16 degrees
Hip internal rotation: Right 15 degrees; Left 27 degrees
Hip external rotation: Right 40 degrees; Left 32 degrees
SLR: Right 20 degrees; Left 33 degrees
Knee flexion: Right 98 degrees; Left 85 degrees
Knee extension: Right minus 30 degrees; Left minus 10 degrees
Ankle Dorsiflexion: Right minus 20 degrees Left minus 30 degrees

Post-testing: Uncompensated ranges of motion after treatment :
Hip flexion: Right 125 degrees; Left 105 degrees
Hip abduction: Right 40 degrees; Left 57 degrees
Hip adduction: Right 16 degrees; Left 5 degrees
Hip internal rotation: Right 33 degrees; Left 38 degrees
Hip external rotation: Right 60 degrees; Left 52 degrees
SLR: Right 88 degrees; Left 65 degrees
Knee flexion: Right 120 degrees; Left 110 degrees
Knee extension: Right 0 degrees; Left minus 10 degrees
Ankle Dorsiflexion: Right minus 20 degrees; Left minus 18 degrees

The results of the treatment were:
a. increased joint mobility of both lower extremities
b. increased uncompensated ranges of motion
c. decreased hypertonicity of both lower extremities
d. reduction in genu varus deformity in supine position
e. improved gait pattern
f. decreased toeing-in of right foot in standing

Home Program:
Client’s mother was instructed to take future vaccination injection sites to her child’s ureters with Neurofascial Process (NFP) for drainage of toxins. Neurofascial Process is a course taught at DCR and was developed in 1986 by Weiselfish-Giammatteo.
Recommendations for IMT to attain further increases in ranges of motion for both lower extremities would be:
Jones’ Strain and Counterstrain Technique (1995) to eliminate/reduce
muscle spasm for: pelvic, knee, and foot/ankle dysfunctions.
3-Planar Myofascial Release and Tendon Release Therapy as warranted (Weiselfish-Giammatteo, 1983).
Lower Extremity Compression Syndrome techniques as warranted (Weiselfish-Giammatteo, 1998).
Medullary Cavity Techniques for long bones in extremities (Weiselfish-Giammatteo, 1998).
Techniques to correct anterior subluxation of talus bilaterally (Weiselfish-Giammatteo, 1998).
Assess for descended sacrum and administer techniques to correct if warranted (Weiselfish-Giammatteo, 1998).

 

 

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CLINIC FOR CHILDREN 

Yudhasmara Foundation

JL Taman Bendungan Asahan 5 Jakarta Indonesia 102010

phone : 62(021) 70081995 – 5703646

http://childrenclinic.wordpress.com/

 

 

Clinical and Editor in Chief :

DR WIDODO JUDARWANTO

email : judarwanto@gmail.com

 

 

 

 

 

                                                                                                            

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider.

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