Key Words: In-toeing, genu varus, pediatric
Abstract: This pediatric client was thirteen months old at evaluation. The mother brought the infant for evaluation and treatment with Integrative Manual Therapy (IMT) for complaints of in-toeing. Between 6 and 10 months, the child was observed repeatedly by the mother to resist weightbearing on the left lower extremity when standing or ambulating with assistance. During ambulation, she was observed toeing-in with her left foot and she displayed a severe genu-varus in bilateral lower extremities. The child’s physician recommended the possibility of using leg splints if the problem persisted. The infant was treated with IMT for her lower extremities. She was treated with lower extremity Compression Syndromes, including Osseous Compression Syndromes, Osseous Torsions, and techniques for her Medullary Cavities. The client was treated for a total of four hours. After therapy was completed, the infant presented with increased joint mobility of both lower extremities, increased uncompensated ranges of motion, decreased hypertonicity of both lower extremities, reduction in genu varus deformity in supine position, improved gait pattern, and decreased toeing-in of right foot in standing.
Written by, Charlotte Branch, PT and Nancy Bupte, OTR
February 13, 2001
Introduction
Destini was born January 13, 2000, the second child to the family. Her mother
reported a normal term pregnancy, an uneventful labor lasting 6 hours and
a vaginal delivery. An epidural was administered to the mother during labor.
The mother reported that the child began standing at 6 months and ambulating
without assistance at 10 months. Between 6 and 10 months, the child was observed
repeatedly by the mother to resist weightbearing on the left lower extremity
when standing or ambulating with assistance. During ambulation, she was observed
toeing-in with her left foot and she displayed a severe genu-varus in bilateral
lower extremities. The child’s physician recommended the possibility
of using leg splints if the problem persisted.
On initial intake, on February 7, 2001, the mother reported no significant
problems during the child’s first year of life. There were no significant
falls, illnesses or injuries since birth that may have influenced the deviations
of movement in the lower extremities. The mother did report that the infant
received scheduled vaccinations. She indicated that the injections were typically
administered as one shot in the right thigh and two shots in the left thigh.
Most parents observe the development of their children with a critical eye.
They note when the infant goes from sit to stand, the child’s first step
and listen for the child’s first word. If any ‘abnormal’ pattern
is observed, the pediatrician’s office is usually contacted for consult
and comfort. Today, parents also have a wealth of information at their disposal
through the worldwide web.
If Destini’s mother sought the web for information on bow-leg, she may
run across The Disney Encyclopedia of Children’s Health (2001) which
reports that many children will experience bow legs, usually between 12 -18
months of age, and knock-knees during their third year of life due to developmental
and growth patterns. Dr. Christenson (2001) reports that in-toeing, genu valgus,
genu varus, and pes planus are common orthopedic problems seen in toddlers.
Both web sites indicate that the conditions typically resolve spontaneously
with aging.
If one looked further on the web, he or she would find Moorehead’s Newsletters
(2001) which indicates that vaccinations in America are at an all-time high
and that contrary to alarming reports of side effects of vaccines, “in
nearly every case there is no evidence that vaccines cause such effects except
in very rare and unusual cases” p. 2. The website also reports that a
child should have 20 injections in the first year of life. The excessive use
of vaccinations within the first year of life and the high incidence of orthopedic
development problems in the lower extremities (site of most injections) during
standing and ambulation in the first few years of life makes one question
if there is any correlation between the two entities.
The purpose of this study is to determine if Integrative Manual Therapy Techniques
((Weiselfish) Giammatteo, 1998) can improve biomechanical function including
range of motion, static and dynamic posture and reduction of genu varus and
in-toeing in the lower extremities of a 13 month old child. This study will
also determine if vaccination sites have any influence on the surrounding
structures.
Review of the Literature
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.
Vaccinations
During the first year of life, a child will receive 20 injections containing
vaccines for diphtheria, measles, and percusses (DtaP0, and for measles, mumps
and rubella (MMR), hepatitis B (Hep B), Haemophilus influenzae (Hib), Polio,
and Pneumo-coccal (PCV7) (Moorehead, 2001). Following this year, injections
for Polio, DtaP and MMR are repeated and given between four and six years
of age. Children between 11 and 15 years old generally receive a tetanus and
diphtheria (Td) booster shot. The developers of these vaccines are currently
investigating the possibility of developing a one-shot combination for polio,
hepatitis B, diphtheria, pertussis and tetanus. The plan is that it would
be given as a single injection at 2, 4, and 6 months with booster shots given
at 12 to 15 months and 4 to 6 years.
Multiple studies have suggested vaccination induced side effects which include
local erythemas, fever, irritability, tiredness, general rashes, conjunctivitis,
arthorpathies, peripheral tremor, cough, post-vaccinal meningitis, guillain-barre
syndrome, brachial neuritis, anaphylactic shock, multiple sclerosis, chronic
arthritis (Quak, 2000). Quak (2000) reports that “undesirable reactions
to vaccinations are often the consequence of toxic substances in the vaccine”
p. 6.
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).
Summary
Integrative Diagnostics and IMT were performed on a 13-month-old girl who
presented with in-toeing and genu varum patterns in static and dynamic positions.
These techniques significantly decreased genu varus in supine and decreased
in-toeing in standing and during ambulation. Improvements also noted in this
case study included increased joint mobility of the hip, knee and ankle, improved
weightbearing and gait patterns, and normalization of muscle tone.
The review of literature of various orthopedic developmental problems indicated
that most deformities of the lower extremities are addressed by doing “nothing”
and letting corrections occur with age. With severe cases, the use of splints,
orthotics, serial casting or surgical interventions may be warranted. The
only type of therapy that was suggested with some conditions was stretching.
The writers of this study suggest that further investigation of the use of
Integrative Manual Therapy techniques with these developmental orthopedic
problems is needed. These studies should look at the long term effect of treatment
and the use of these techniques to avoid the painful traditional treatment
methods of splinting, casting or surgery.
The review of the literature also revealed that most vaccinations occur during
the first year of life and some are repeated between four and six years of
age. The literature review reported the incidence of genu-varum occurs from
12 to 18 months of age and genu valgus occurs at two to three years, and was
evident in 5 year olds in a cited study. The subject of this study displayed
genu varum, significant positive Myofascial Mapping on the thighs (the site
of vaccine injections) and positive recoil tension tests for thigh compression
syndromes. The writers of this study recommend further investigation on the
impact of vaccination injection sites and their influence developmental orthopedic
problems. If genu varum and in-toeing is common among infants, is it strictly
developmental patterns of the lower extremity or is there some influence from
the abundance of vaccinations that occur in the first year of life?
Notes
American Academy of Family Physicians. What Parents Need to Know about Intoeing.
Internet: www.vh.org/Patients/IHBB/FamilyPractice/AFP/November/NovOne.html,
November 1994.
Anderson, K. ed. Mosby’s Medical, Nursing, and Allied Health Dictionary, 4th ed.; Mosby:St. Louis, 1994.
Christensen, K. Pediatric Developmental Problems. Internet: www.chiroweb.com/archives/13/02/18.html, February 2001.
Giammatteo, T. and Weiselfish-Giammatteo, S. Integrative Manual Therapy for the Autonomic Nervous System and Related Disorders, North Atlantic Books: 1997.
Jones, L. H. Strain-Counterstrain, Jones Strain-Counterstrain, Inc.: Boise, 1995.
Midwest Orthopedic Surgeons. Health Line-Intoeing. Internet: www.orthoscope.com/intoeing.htm. February 2001.
Moorehead. Immunizations. Internet:www.moorehead.org/wellconnected/doc90.html, September 2000.
Palastanga, N., Field, D. and Soames, R. Anatomy and Human Movement Structure and Function, Heinemann Medical Books: Oxford, 1989.
Quak, T. translated by Kurz, C. Vaccinations and their side effects. Internet: www.med.uni-muenchen.de/fachschaft/homeopathy/vaccine.htm, February, 2001.
The Disney Encyclopedia of Children’s Health. Raising Kids. Internet: http://family.go.com, February 2001.
Weiselfish-Giammatteo, S. Integrative Manual Therapy for the Low Back and Spine Advanced Clinical Biomechanics of Sacrum, Dialogues in Contemporary Rehab: Bloomfield, 1998.
Weiselfish-Giammatteo, S. Integrative Manual Therapy for the Upper and Lower Extremities, North Atlantic Books: Berkeley, 1998.
Weiselfish-Giammatteo, S. Lower Extremity Compression Syndrome, Dialogues in Contemporary Rehab: Bloomfield, 1998.
Weiselfish-Giammatteo, S. Myofascial Release. Dialogues in Contemporary Rehab: Bloomfield, 1983.