1. Infant lower extremity examination American College of Osteopathic Pediatricians Robert W Hostoffer, DO FACOP edited by Eric Hegybeli, DO, FACOP

2. Background: Andrew Taylor Still, was born in Virginia in 1828, the son of a Methodist minister and physician. At an early age, Still decided to follow in his father's footsteps as a physician. After studying medicine and serving an apprenticeship under his father, Still became a licensed M.D. in the state of Missouri. Later, in the early 1860's, he completed additional coursework at the College of Physicians and Surgeons in Kansas City, Missouri. He went on to serve as a surgeon in the Union Army during the Civil War.

3. Background: After the Civil War and following the death of three of his children from spinal meningitis in 1864, Still concluded that the orthodox medical practices of his day were frequently ineffective, and sometimes harmful. He devoted the next ten years of his life to studying the human body and finding better ways to treat disease.

4. Background: His research and clinical observations led him to believe that the musculoskeletal system played a vital role in health and disease and that the body contained all of the elements needed to maintain health, if properly stimulated. Still believed that by correcting problems in the body's structure, through the use of manual techniques now known as osteopathic manipulative treatment, the body's ability to function and to heal itself could be greatly improved. He also promoted the idea of preventive medicine and endorsed the philosophy that physicians should focus on treating the whole patient, rather than just the disease. http://www.aacom.org/OM/history.html

5. Causes of Intoe Gait Causes of Intoe Gait

6. Normal - - - - - - - Intoe Gait Normal - - - - - - - Intoe Gait

7. Metatarsus Adductus

8. Metatarsus adductus, also known as metatarsus varus, is a common foot deformity noted at birth that causes the front half of the foot, or forefoot, to turn inward. Metatarsus adductus may also be referred to as "flexible" (the foot can be straightened to a degree by hand) or "non-flexible" (the foot cannot be straightened by hand).

9. Causes of Metatarsus Adductus The cause of metatarsus adductus is not known. It occurs in approximately one out of 1,000 live births and affects girls and boys equally. Other causal factors include the following: family history of metatarsus adductus position of the baby in the uterus, especially with breech presentations sleeping position of the baby (babies sleeping on their stomach may increase the tendency of the feet to turn inward) Babies born with metatarsus adductus may also be at increased risk of having an associated hip condition known as developmental dysplasia of the hip (DDH). DDH is a condition of the hip joint in which the top of the thigh (femur) slips in and out of its socket, because the socket is too shallow to keep the joint intact.

10. Treatment observation, for those with a supple, or flexible, forefoot passive osteopathic manipulation exercises casts surgery

11. Tibiofemoral Angle

12. Salenius 1975

13. Internal Tibial Torsion

14. Internal Tibial Torsion (ITT) is a condition in early childhood in which the tibia (leg bone) is twisted inwards axially, causing the child to intoe as he walks. This is a very common condition -and considered normal unless it does not resolve beyond 18 to 24 months of age. ITT is universal in infants and toddlers, and when the child takes his first steps, intoeing is the norm. With walking, the ITT resolves, and disappears by 18 to 24 months of age. Osteopathically, internal rotation of the tibia is caused by a dropped navicular (causes excessive pronation of the foot); internal rotation of the tibia could be a cause of ITT

15. Thigh-Foot angle In a child 18 months of age, it should be between -10 degrees to +10 degrees. worse than -45 degrees should be treated

16. Thigh Foot Angle Thigh Foot Angle

17. External Tibial Torsion

18. Excess Femoral Anteversion

19. Femoral Anteversion Femoral Anteversion

20. Barlow & Ortolani Tests

21. Print out the answer sheet to use with the following questions.

22. Circle the correct answer and review with director: Question1: A, B, C, D, E. Question2: A, B, C, D, E. Question3: A, B, C, D, E.

23. Questions: 1. Reasons for intoeing in the pediatric patient: – A. Femoral anteversion – B. Internal tibial torsion – C. Metatarsus abductus – D. External tibial torsion – E. Otarni’s inversion

24. Question: 2. Abnormal thigh-foot angle : – A. -40 – B. 45 – C. -45 – D. -35 – E. -30

25. Question: 3. The following are causes of metatarsus adductus except: – A. Sleeping position – B. In utero position – C. family history of MA – D. Sleeping on stomach – E. Dysplasia of the hip

26. Certificate of Completion I, _________________________, successfully completed the Pediatric OMT Module on __ __ 20__ Signatures: Pediatric Resident ____________________ Pediatric Residency Director____________ ( Please print and give to program director.)

27. Congratulations