PEDIATRIC FLATFOOT
Most children with flatfoot have no symptoms, but some children have one or more symptoms. When symptoms do occur, they vary according to the type of flatfoot. Some signs and symptoms may include:
- Pain, tenderness, or cramping in the foot, leg, and knee.
- Outward tilting of the heel.
- Awkwardness or changes in walking.
- Difficulty with shoes.
- Reduced energy when participating in physical activities.
- Voluntary withdrawal from physical activities Flatfoot can be apparent at birth or it may not show up until years later, depending on the type of flatfoot. Some forms of flatfoot occur in one foot only, while others may affect both feet.
Types of Pediatric Flatfoot
Various terms are used to describe the different types of flatfoot. For example, flatfoot is either asymptomatic (without symptoms) or symptomatic (with symptoms). As mentioned earlier, the majority of children with flatfoot have an asymptomatic condition. Symptomatic flatfoot is further described as being either flexible or rigid . “Flexible“ means that the foot is flat when standing (weight bearing), but the arch returns when not standing. “Rigid” means the arch is always stiff and flat, whether standing on the foot or not. Several types of flatfoot are categorized as rigid. The most common are:
Tarsal coalition – This is a congenital (existing at birth) condition. It involves an abnormal joining of two or more bones in the foot. Tarsal coalition may or may not produce pain. When pain does occur, it usually starts in preadolescence or adolescence.
Congenital vertical talus – Because of the foot’s rigid “rocker bottom” appearance that occurs with congenital vertical talus, this condition is apparent in the newborn. Symptoms begin at walking age, since it is difficult for the child to bear weight and wear shoes. There are other types of pediatric flatfoot, such as those caused by injury or some diseases.
Diagnosis
In diagnosing flatfoot, the foot and ankle surgeon examines the foot and observes how it looks when the Pediatric flatfoot Normal pediatric foot child stands and sits.
The surgeon also observes how the child walks and evaluates the range of motion of the foot. Because flatfoot is sometimes related to problems in the leg, the surgeon may also examine the knee and hip. X-rays are often taken to determine the severity of the deformity. Sometimes an MRI study, CT scan, and blood tests are ordered.
Treatment: Non-surgical Approaches
The surgeon also observes how the child walks and evaluates the range of motion of the foot. Because flatfoot is sometimes related to problems in the leg, the surgeon may also examine the knee and hip.
X-rays are often taken to determine the severity of the deformity. Sometimes an MRI study, CT scan, and blood tests are ordered. If a child’s flatfoot is asymptomatic, treatment is often not required.Instead, the condition will be observed and re-evaluated periodically by the foot and ankle surgeon.Custom orthotic devices may be considered for some cases of asymptomatic flatfoot. In symptomatic pediatric flatfoot, treatment is required. The foot and ankle surgeon may select one or more approaches, depending on the child’s particular case. Some examples of non-surgical options include:
Activity modifications -The child needs to temporarily decrease activities that bring pain as well as avoid prolonged walking or standing.
Orthotic devices – The foot and ankle surgeon can provide custom orthotic devices that fit inside the shoe to support the structure of the foot and improve function.
Physical therapy – Stretching exercises, supervised by the foot and ankle surgeon or a physical therapist, provide relief in some cases of flatfoot.
Medications – Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to help reduce pain and inflammation.
Shoe modifications -The foot and ankle surgeon will advise you on footwear characteristics that are important for the child with flatfoot.
When Is Surgery Needed?
In some cases, surgery is necessary to relieve the symptoms and improve foot function. Foot and ankle surgeons perform a variety of techniques to treat the different types of pediatric flatfoot. The surgical procedure or combination of procedures selected for your child will depend on his or her particular type of flatfoot and degree of deformity.
PEDIATRIC HEEL PAIN
What Is Pediatric Heel Pain
Heel pain is a common childhood complaint. That doesn’t mean, however, that it should be ignored, or that parents should wait to see if it will “go away.” Heel pain is a symptom, not a disease. In other words, heel pain is a warning sign that a child has a condition that deserves attention.
Heel pain problems in children are often associated with these signs and symptoms:
- Pain in the back or bottom of the heel.
- Limping.
- Walking on toes.
- Difficulty participating in usual activities or sports.
The most common cause of pediatric heel pain is a disorder called calcaneal apophysitis (see below),which usually affects 8- to 14-year olds. However, pediatric heel pain may be the sign of many other problems, and can occur at younger or older ages.
What Is the Difference Between Pediatric and Adult Heel Pain?
Pediatric heel pain differs from the most common form of heel pain experienced by adults (plantar fasciitis) in the way pain occurs. Plantar fascia pain is intense when getting out of bed in the morning or after sitting for long periods, and then it subsides after walking around a bit.
Pediatric heel pain usually doesn’t improve in this manner. In fact, walking around typically makes the pain worse. Heel pain is so common in children because of the very nature of their growing feet. In children, the heel bone (the calcaneus) is not yet fully developed until age 14 or older. Until then, new bone is forming at the growth plate (the physis), a weak area located at the back of the heel. Too much stress on the growth plate is the most common cause of pediatric heel pain.
Causes of Pediatric Heel Pain
There are a number of possible causes for a child’s heel pain. Because diagnosis can be challenging, a podiatric foot and ankle surgeon is best qualified to determine the underlying cause of the pain and
develop an effective treatment plan. Conditions that cause pediatric heel pain include:
Calcaneal apophysitis – Also known as Sever’s disease, this is the most common cause of heel pain in children.Although not a true “disease,” it is an inflammation of the heel’s growth plate due to muscle strain and repetitive stress, especially in those who are active or obese. This condition usually causes pain and tenderness in the back and bottom of the heel when walking, and the heel is painful when touched. It can occur in one or both feet.
Tendo-Achilles bursitis – This condition is an inflammation of the fluid-filled sac (bursa) located between the Achilles tendon (heel cord) and the heel bone.
Tendo- Achilles bursitis can result from injuries to the heel, certain diseases (such as juvenile rheumatoid arthritis), or wearing poorly cushioned shoes.
Overuse syndromes -Because the heel’s growth plate is sensitive to repeated running and pounding on hard surfaces, pediatric heel pain often reflects overuse. Children and adolescents involved in soccer, track, or basketball are especially vulnerable. One common overuse syndrome is Achilles tendonitis. This inflammation of the tendon usually occurs in children over the age of 14.Another overuse syndrome is plantar fasciitis, which is an inflammation of the band of tissue (the plantar fascia) that runs along the bottom of the foot from the heel to the toes.
Fractures – Sometimes heel pain is caused by a break in the bone. Stress fractures -hairline breaks resulting from repeated stress on the bone-often occur in adolescents engaged in athletics, especially when the intensity of training suddenly changes. In children under age of 10, another type of break- acute fractures -can result from simply jumping 2 or 3 feet from a couch or stairway.
Diagnosis of Pediatric Heel Pain
To diagnose the underlying cause of your child’s heel pain, the podiatric surgeon will first obtain a thorough medical history and ask questions about recent activities.
The surgeon will also examine the child’s foot and leg. X-rays are often used to evaluate the condition, and in some cases the surgeon will order a bone scan, a magnetic resonance imaging (MRI) study, or a computerized tomography (CT or CAT) scan. Laboratory testing may also be ordered to help diagnose other less prevalent causes of pediatric heel pain.
Treatment Options
The treatment selected depends upon the diagnosis and the severity of the pain. For mild heel pain, treatment options include:
Reduce activity – The child needs to reduce or stop any activity that causes pain.
Cushion the heel – Temporary shoe inserts are useful in softening the impact on the heel when walking, running, and standing. For moderate heel pain, in addition to reducing activity and cushioning the heel, the podiatric surgeon may use one or more of these treatment options:
Medications – Nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, help reduce pain and inflammation.
Physical therapy – Stretching or physical therapy modalities are sometimes used to promote healing of the inflamed tissue.
Orthotic devices – Custom orthotic devices prescribed by the podiatric surgeon help support the foot properly. For severe heel pain, more aggressive treatment options may be necessary, including:
Immobilization – Some patients need to use crutches to avoid all weight-bearing on the affected foot for a while. In some severe cases of pediatric heel pain, the child may be placed in a cast to promote healing while keeping the foot and ankle totally immobile.
Follow-up measures – After immobilization or casting, follow-up care
often includes use of custom orthotic devices, physical therapy, or strapping.
Surgery– There are some instances when surgery may be required to lengthen the tendon or correct other problems.
Can Pediatric Heel Pain Be Prevented?
The chances of a child developing heel pain can be reduced by following these ecommendations:
- Avoid obesity
- Choose well-constructed, supportive shoes that are appropriate for the child’s activity
- Avoid, or limit, wearing cleated athletic shoes . Avoid activity beyond a child’s ability
If Symptoms Return
Often heel pain in children returns after it has been treated because the heel bone is still growing. Recurrence of heel pain may be a sign of the initially diagnosed condition, or it may indicate a different problem. If your child has a repeat bout of heel pain, be sure to make an appointment with your Podiatrist.
This information has been prepared by the Consumer Education Committee of the American College of Foot and Ankle Surgeons, a professional society of 5,700 podiatric foot and ankle surgeons.Members of the College are Doctors of Podiatric Medicine who have received additional training through surgical residency programs. The mission of the College is to promote superior care of foot and ankle surgical patients through education, research and the promotion of the highest professional standards. Copyright © 2004, American College of Foot and Ankle Surgeons . www.acfas.org