October 26, 2021
Useful
Osteochondrosis of the lower limb is a disease characteristic of childhood. The stresses that a child's bones experience affect the growth plate and can lead to disruptions in its development.
It is important for a pediatrician to know the main signs of this disease so as not to miss it in young patients.
The faster a child develops, the more vulnerable growth points become. This is especially noticeable in boys aged 4, 7-8 and 12 years. That is, at the age when the next growth spurt occurs and children begin to actively engage in sports. And parents worry about their sports success.
What to pay attention to, how not to miss the onset of the disease or its complications was discussed with Olga Chizhevskaya, executive director of the League for the Promotion of Podiatry.
Signs of susceptibility to osteochondrosis
Bone develops from hyaline cartilage, in which the processes of ossification and calcification gradually occur. And by the time of birth, the only areas where hyaline cartilage remains are the articular surface and the growth plate area. Moreover, in the latter we observe the presence of cartilage even during the period of skeletal maturation. That is, this area remains vulnerable even in adulthood.
There are three main factors that influence the development of osteochondrosis: the intensity of growth, the weight of the child and his activity.
The child's weight is associated with the vertical load on the foot and lower limb. When the optimal body weight is exceeded, the foot experiences additional stress, which can lead to both the development of flat feet and more serious problems, including osteochondrosis.
“Growth spurts often coincide with the start of a particular sport. If swimming or cycling unload the foot, then running or football with increased vertical loads, on the contrary, contribute to the development of degenerative changes.
In this case, it is useful to alternate between different sports. This will help not only reduce the risk of developing osteochondrosis, but also harmoniously develop the musculoskeletal complex and even allow the child to achieve more significant sports results,” says Vladimir Nechaev, orthopedic traumatologist, chiropractor, sports doctor, osteopath.
How to treat protruding bones?
Before treating protruding bones of the lower extremities, an accurate diagnosis must be made. For some diseases, help can only be provided through surgery. Thus, in advanced cases of deforming osteoarthritis of the knee or hip joint, only endoprosthetic surgery can restore their normal state.
Many pathologies that cause protrusion of the bones of the lower extremities can be successfully treated using conservative methods of manual therapy. Thus, with hallux valgus and varus deformities of the lower extremities, flat feet and club feet, the normal state of the musculoskeletal system can be restored. To do this, in our manual therapy clinic we use the following methods of influence:
- therapeutic exercises and kinesiotherapy help to form the normal position of the bones and strengthen the muscular frame of the lower extremities;
- massage and osteopathy increase the elasticity of soft tissues, enhance microcirculation of blood and lymphatic fluid, and trigger recovery processes;
- reflexology starts the process of regeneration of damaged tissue;
- physiotherapy and laser treatment can improve the general condition of bone tissue.
In addition, an experienced doctor gives the patient comprehensive individual recommendations on diet, physical activity regimen, choosing suitable shoes, etc.
If you need help from an orthopedist, you can get it in our manual therapy clinic. The initial doctor's appointment for each patient is provided completely free of charge.
Diagnosis of osteochondrosis
The first thing a doctor should pay attention to when diagnosing osteochondrosis of the lower extremities is the patient’s age. Due to the physiology of the development of the skeletal system, different parts and bones are most vulnerable at different periods of life.
The second is clinical signs. Most often this is pain without signs of inflammation. If a local increase in temperature, redness of the skin and swelling is observed in the affected area, more serious inflammatory diseases may develop.
The third diagnostic criterion is the results of x-ray examination. But they can only be valid if there is a clinical picture.
Mechanism of damage
Two mechanisms of damage have been proposed:
- Plantar flexion and inversion injuries: During rapid plantar flexion and inversion injuries (a mechanism of lateral ankle sprain), a strong reflex contraction of the peroneus longus muscle occurs. In this case, the cuboid bone acts as a center of rotation, and the tendon transfers the load to the cuboid bone, causing inferomedial displacement, in other words, subluxation of the cuboid bone.
- Overuse syndrome: This mechanism is poorly described and rare, but it has been suggested that cuboid subluxation occurs secondary to repeated microtrauma (in case of return to vigorous activity).
Predisposing factors:
- instability of the articulation of the tarsal bones with each other;
- excess body weight;
- ill-fitting or poorly designed orthoses or shoes;
- physical exercise (intensity, duration, frequency);
- training on uneven surfaces;
- sprained foot or ankle;
- Cuboid syndrome may be more prevalent in patients with pronated feet due to increased leverage of the peroneus longus muscle.
Kohler's disease – osteochondrosis of the scaphoid bone
This is an uncommon variant of osteochondrosis, occurring in boys aged 2 years and older. At this age, the child begins to walk, the foot begins to experience weight bearing, and secondary foci of ossification appear in the scaphoid bone.
With this disease, the child simply refuses to put any weight on the affected leg and refuses to walk. Attempts to examine and palpate also cause severe pain and crying. In this situation, only careful superficial palpation is possible, during which pain can be detected specifically in the area of the scaphoid bone.
The main danger of this condition is that aseptic necrosis may develop. It is also always worth remembering the risk of complications, including infectious ones. Therefore, if the examination reveals not only pain, but also signs of inflammation, it is worth taking a particularly careful approach to diagnosis.
The simplest treatment method is to apply a plaster immobilizing bandage for 4-6 weeks. Also, depending on the individual foot condition, orthoses may be used to relieve weight on the affected limb. When selecting treatment, you should always pay attention to the severity of the pain syndrome and the rate of restoration of function of the lower limb when the weight load is reduced. Sever's disease – apophysitis of the calcaneus
The most common type of osteochondrosis of the foot. The disease develops in children aged 7-14 years. It is at this age that a secondary ossification center appears in the calcaneus. These children will complain of heel pain after playing sports and occasional limping. If the heel is squeezed during examination, the child will feel pain.
Clinically, the doctor must confirm that it is the apophysis that is affected, and not the heel bone or ankle joint itself. If there are signs of inflammation or the child complains of pain not only after playing sports, but also during other periods, then it is worth taking a more careful approach to the diagnosis to exclude complications, including idiopathic juvenile arthritis.
During treatment, it can be recommended to stretch the calf muscle group and use shoes with high heel pads to relieve the necessary parts of the foot and growth plate. With the correct selection of shoes, the child can return to sports and continue training.
Protruding navicular and metatarsal bones on the foot
The navicular bone of the foot is located next to the ankle joint. It borders the talus and cuboid bones. It forms the talonavicular joint, which provides mobility to the foot. The longitudinal muscular arch begins at this point. When flat feet or club feet develop, the scaphoid bone protrudes. With the development of longitudinal flatfoot, the navicular bone moves down and begins to protrude from the side of the sole, causing a lot of unpleasant sensations while walking. Arthrosis of the talonavicular joint quickly forms and stiffness appears. When walking, extraneous sounds (crunching, creaking) may occur.
When an incorrect foot alignment occurs in the form of a clubfoot, the navicular bone rises and it begins to protrude on the top of the foot near the ankle joint. This condition also quickly provokes the breakdown of cartilage tissue and the development of deforming osteoarthritis with contracture and stiffness.
The metatarsal bones of the foot are located between the tarsus and phalanges of the toes. There are five of them. They are often exposed to a variety of traumatic influences. Even a minor bruise can provoke the formation of a hematoma in the periosteum area. It will appear as if the metatarsal bone is sticking out, but it is actually a sign that a tumor has formed on the bone tissue.
A protruding bone in the foot is not always a sign of an orthopedic disease. It is important to differentially diagnose pathologies of the ligamentous, tendon and muscular apparatus. Myomas, fibromas, endotheliomas are neoplasms that, upon palpation, can be described as bone growths, they are so dense and hard. But from the simplest X-ray image it can already be determined that this is not a bone structure. To make an accurate diagnosis, an MRI examination, puncture, and biopsy of materials for histological examination may be required (to exclude oncological tumors).
In most cases, a protruding metatarsal bone indicates improperly healed fragments after a fracture that was not diagnosed in a timely manner. If complete immobility is not ensured after a fracture, a rough, extensive callus will form, which may look like a large growth protruding through the skin.
Perthe disease – osteochondrosis of the hip joint
This disease develops from age 4 and affects children under 10 years of age. Boys get sick 4 times more often than girls. As a rule, the joint is affected only on one side, although bilateral disease is possible.
Clinically manifested by lameness. Upon examination, the child has a reduced range of motion in the affected hip joint compared to the healthy one. The radiograph shows fragmentation of the articular surface.
Also, this type of osteochondrosis can manifest itself as pain in the knee. Therefore, if, with characteristic complaints during examination, there are no structural changes specifically in the knee area, it is worth paying attention to the hip joint.
Management of such a patient involves mainly rest and unloading of the affected limb. But it is difficult for a child at this age to give up activity. In this case, you can replace running with swimming to relieve the load on the hip joint.
Clinical manifestations
The symptoms of cuboid syndrome resemble those of a sprained ligament. Pain is often dispersed along the lateral aspect of the foot between the calcaneocuboid joint and the 4th and/or 5th cuboid-metatarsal joints and may spread throughout the entire foot. A subtle groove on the dorsum of the cuboid and/or a subtle bump (thickening) on the plantar surface may be seen with subluxation with skin redness, swelling and/or bruising. Tenderness may occur along the peroneus longus muscle, the cuboid groove, the posterolateral and/or plantar orientation of the cuboid, or the origin of the extensor digitorum brevis muscle. Active or passive range of motion of the ankle and/or foot may be reduced with pain. Resistance of the ankle/foot eversion/inversion may cause pain. In SCS, there is an antalgic gait with pain and/or weakness, most pronounced during push-off or when moving from side to side. Jumping can cause symptoms that increase with weight bearing and decrease when weight is removed.
Treatment
According to various sources, for the initial stage of treatment of cuboid bone syndrome, procedures with the cuboid bone are recommended unless contraindicated (bone defects, inflammatory arthritis, gout, neurological or vascular disorders, fractures). Two treatment approaches have been described: reduction and compression of the cuboid. For the cuboid reduction procedure, cupping is placed on the dorsum of the patient's forefoot, placing the big toe on the plantomedial aspect of the cuboid. The patient's knees are flexed to an angle of 70° - 90° while the ankle joint is placed at an angle of 0° in dorsiflexion. While the patient's foot is at rest, the physician sharply realigns the foot into inversion and plantar flexion, applying low-amplitude, high-velocity pressure (through the big toe) to the cuboid bone. A pop or shift may be heard and/or felt by the physician and/or patient during the procedure. While compressing the cuboid, the physician slowly stretches the ankle to maximum plantar flexion and the foot and toes to maximum flexion. When the doctor feels that the soft tissues on the dorsal side are relaxed, the cuboid bone is “compressed” (load on the dorsal side) with the thumbs. Cuboid compression cannot be used in patients with a corresponding lateral ankle dislocation because the ankle is in maximum plantar flexion prior to the procedure. Cuboid procedures should only be attempted when swelling and bruising have significantly improved and the ankle capsule and ligament injuries have been properly treated (tolerance of procedural stress is required). Raising the calcaneal tuberosity increases stress tolerance and/or reduces discomfort during passive dorsoplantar translation of the cuboid, which may indicate improvement after the procedures.
Patients who experience partial or incomplete symptoms may benefit from additional procedures to ensure a good recovery. The presence of a relationship between the duration of symptoms and the number of procedures is necessary to compile a complete symptomatology. Some patients who experience minor discomfort after procedures may benefit from cryotherapy, ultrasound (without heat), transcutaneous electrical stimulation, or massage. Patients should avoid strenuous physical activity (such as running) for several days after procedures. After successful procedures, recurrence of the injury can be prevented by using taping, orthoses, and the use of a soft cuboid pad. Various taping technologies have the common goal of supporting the medial longitudinal arch of the foot. For SBS, a soft pad is usually recommended to support the cuboid bone inferiorly. The size, thickness, and placement of the pad underneath the medial aspect of the cuboid control the prevention of cuboid eversion (noticeable at sizes 1/8 or 1/4 [3-6 mm]). A lateral wedge under the heel bone may also help reduce pain when putting weight on the foot.
Diagnostic procedures
Although there are no clinically validated tests for diagnosing SBS, two clinical techniques have been described: the midtarsal adduction (midplane rotation) test and the midtarsal supination test. During the adduction test, the tarsal joint passively moves in the transverse plane (above/below the axis) while stabilizing the calcaneus. During this technique, the medial part of the calcaneocuboid joint is compressed and its lateral part is relaxed. Supination is a similar technique with the addition of inversion (frontal plane) and plantar flexion (sagittal plane). Pain can also be caused by passive dorsal or plantar movement of the cuboid. This movement is reduced when the cuboid is in a locked position. The diagnostic accuracy of these techniques has not been determined.