Pediatric Page
Introduction
If it were possible to walk the circumference of the globe, would you? Well, according to the American Podiatric Medical Association, your feet travel upwards of 115,000 miles in a lifetime - the equivalent of walking around the globe four times. Providing some thought and care at an early age can greatly enhance the quality of those walked miles. It is important to remember that when it comes to your child there are no silly questions. Ask yourself: Did you or your spouse ever walk pigeon-toed, bow-legged, or have flat feet? Did you "outgrow" the problem or do you still suffer with the same condition? The answers are important since structural problems tend to be inherited.
By ordering Little Steps: A Parent's Guide to Your Child's Foot Health, you have taken the first step in recognizing the importance of your child's feet in a healthier life. My name is Dr. Peter Bregman and I am the founder of Northeast Foot & Ankle Specialists, PC. I'm a podiatrist, which simply means that we are specialists in the care and treatment of feet and ankles. I wrote this book to help you understand what could be happening with your child's feet and what help is available from a podiatrist. Our purpose here is to offer parents insight into what is "normal" and "abnormal" in regards to a child's foot health, and to help answer one of the most common questions heard among the pediatric medical community, "Is my child walking correctly?"
If after reading this book you think you and your child might be helped by seeing a podiatrist, we hope you consider Northeast Foot & Ankle Specialists, PC. Whether it's an ingrown nail or a fractured ankle, we will do everything we can to treat the condition, eliminate the pain and treat your family as if they were our family.
We love kids, and we devote ourselves to the mechanics of their feet and ankles because we want them to have the most positive results over the long term. For additional information on foot and ankle conditions and services offered at NEFAS, we encourage you to visit our website - www.painfreefeet.com. Our website is a true extension of our practice, providing patient education, contact information, and office forms to make your life easier.
Dedicated to Your Health,
Dr. Peter J. Bregman
What Can a Podiatrist Do For Your Child's Foot?
Let's first answer the question, "What is Podiatry?" Podiatry is a branch of medicine that deals with the examination, diagnosis, and treatment of conditions and functions of the human foot and ankle by medical and surgical methods.
Next, let's answer the question, "How does a Podiatrist (DPM) differ from an Orthopedist (MD or DO)?" A podiatrist has a doctorate degree in podiatric medicine (DPM) as opposed to allopathic medicine (MD) and osteopathic medicine (DO). DPM, MD and DO physicians all have the same undergraduate prerequisites and attend a 4 year medical school. The major difference is that DPM's actually take more classes in regard to lower extremity anatomy, surgery, biomechanics, and bracing. DPM's choose their specialty from day one, thus giving focus toward the specialty 5 years earlier than other doctors.
From medical school through residency training, DPM's, MD's and DO's rotate through all specialties and have the same requirements, guidelines, and demands. All three types of physicians have the same hospital surgical-medical privileges. The primary difference is the consideration of a patient's biomechanics in regard to conservative and surgical treatment. DPM's not only prescribe orthotics and braces, but are directly involved in their design, construction, and follow-up to assure they are effective. Moreover, an orthopedist's training in the foot and ankle focuses mostly on surgery even though conservative care could alleviate symptoms.
When medically necessary, podiatrists perform surgery to correct or remedy problems. Surgery may be as simple as removing a small skin lesion or as complex as reconstructing a severe flatfoot deformity or broken ankle. Before we recommend surgery, we explore the many conservative therapies that are available and then recommend the very best course of treatment.
Rest assured, the DPM's at Northeast Foot & Ankle Specialists, PC are highly trained specialists capable of handling all of your family's foot and ankle needs. We have experience and knowledge specific to the pediatric foot and ankle. We exceed all state and national requirements for continuing medical education to bring the most up-to-date treatment and techniques to our community.
Normal Development
From birth, every parent is concerned about their child's feet. We watch in both awe and wonder as our children grow and develop, especially during the first few years of life. As a parent, we do everything in our power to ensure that our children remain healthy and develop normally. However, "normalcy" is difficult to define when it comes to the child's ability to walk, especially in light of all of the changes that occur during development. This is complicated by the fact that parents are often confused when it comes to "normal" foot development due to conflicting advice from grandparents, family, well-meaning neighbors, general pediatricians, orthopedic doctors, chiropractors, and podiatrists.
Normal Growth
Infants, those under the age of 16-18 months, grow more than half a foot size every two months. Toddlers from the ages of 16 to 24 months grow an average of half a foot size every three months. When children are 24 to 36 months old they grow approximately half a foot size every four months. Over 3 years of age, children increase half a foot size every four to six months.
It will take approximately 18 years for a child's foot to fully develop. At birth, the foot contains 22 partially developed bones. Over the next 13 to 14 years many of these will fuse together to form the 26 bones that make up the mature adult foot. During the first year, each foot will reach almost half its adult size. This is why podiatrists consider the first year as most important in the development of the feet.
The American Podiatric Medical Association offers the following tips for normal infant foot development:
- Inspect your baby's feet often. If something doesn't look normal to you, ask your podiatrist or pediatrician.
- Provide opportunity for exercise. Lying uncovered enables kicking and other related motions which prepare the feet for weightbearing.
- Change the baby's position several times a day. Too long in one spot can put excessive strain on the feet and legs.
- Cover the baby's feet loosely. Tight covers restrict movement and can delay development.
The Development of Walking
Seeing a child take their first step is described as one of the most memorable moments in a parent's life. During the first year, your child has been developing muscle strength and coordination, mastering one physical feat after another, from sitting to rolling over to crawling. At about eight months your child will probably start pulling up onto furniture and walls. Shortly thereafter, the child will begin to move around while holding onto the furniture, known as 'cruising'. Children will begin to walk unassisted only when they are ready - typically occurring between the ages of 9-18 months. It is extremely important not to rush your child into walking since speeding up the "internal walking clock" may actually prove detrimental to their normal development. Around 14 months the child has abandoned crawling as the only means of getting around and can toddle a few steps. Naturally, the child's mobility is uncontrolled at this early stage of walking. Braking and steering systems haven't developed sufficiently to stop or swerve to avoid objects.
By their second birthday the majority of children are sure-footed although spills can and do occur. From about 2 years old the child becomes confident in all aspects of walking, running and jumping. In fact, a child of three will have developed nearly all the walking skills he or she will have as an adult of thirty.
As a child grows, parents will notice a change in the knee position. From the first steps until about the age of 2, a child will appear to be bowlegged (a condition know as genu-varum) which means there will be a gap between the knees when the child is standing with both feet next to each other. This is normal. The child will then go through a stage of being knock-kneed (genu-valgum), where the knees angle inwards when the child attempts to place the feet together. This stage is also normal from approximately 2-6 years of age. After 6, the condition typically corrects itself. If either of these stages persist or become excessive, it is a good idea to follow-up with your pediatrician and/or podiatrist as soon as possible, since both of these conditions can be associated with other problems.
Growing Pains
Growing pains are a sign that something is wrong. When pain is present in the body it is an indication that something is wrong. This is NOT normal and needs to be addressed. It is usually related to a muscle or tendon imbalance in the child's feet or legs, especially if active.
Shoe Shopping
While most parents recognize the need for correctly fitting shoes during a child's early years of walking life, few realize that children's feet remain vulnerable to ill-fitting shoes right through their school days, up to the age of 18 years or so. It is a concerning fact that many children suffer foot problems by their early teens, often associated with ill-fitting shoes. Yet if parents sustain vigilance throughout the foot's 18 formative years, the majority of foot problems may simply never occur.
The function of a child's shoe is to prevent injury from sharp objects, insulate feet from excessive temperatures, and protect during the stomping or kicking that can occur when agitated. These environmental threats are an unfortunate side effect of modern day living. For adults, the shoe industry has become increasingly centered on shoe fashion and the marketing of shoes as a status symbol. However, in children, shoes have maintained their original role of protection from the hazards of the outside world.
According to most experts, shoes are not recommended for pre-walking infants since the bones and ligaments in their feet are still flexible, rapidly developing and prone to deforming forces. In fact, a stiff shoe can decrease a child's ability to balance and cause frequent falling. A soft warm bootie is the preferred shoe of choice until the child is able to walk unassisted. Once walking, a flexible shoe is preferred to allow for normal foot function.
While there seems to be a large array of opinions regarding shoes, most experts agree that the proper shoe for children should be flexible, light, and made of breathable materials. If the shoe is too heavy or rigid, the foot will not develop normally. The heel counter should really be the only rigid part of the shoe. This is the part of the shoe that surrounds the heel and provides the greatest amount of support. The shoe should flex at the forefoot and midfoot, but not at the heel counter. Some suggest a high top sneaker to add stability, but there is controversy with this since they can act as a 'brace' and disrupt the normal development of the muscles that support the foot and ankle.
Children's feet grow at a rapid and unpredictable pace due to the fact that they tend to grow in spurts. This is often very frustrating to parents since the cost of quality children's shoes is about one-half that of the adult's version. Parents should be advised that saving money by "passing down" shoes from older children can be problematic since every child wears their shoes differently. While the size may be just right, the old wear pattern of the shoe may throw off the normal gait in the new owner. Since the support of the shoe is most likely compromised, an older pair of shoes should be carefully inspected prior to being passed down.
Perhaps the most acceptable way of increasing the life of a shoe is to buy the shoe slightly bigger than the child's measured length. It is better to be too big than too small in terms of shoe fit. There should be about three-quarters of an inch from the longest toe (not always the first) to the tip of the shoe. Also, check to see that the child's foot is not lifting out of the heel or that the child doesn't trip over the shoe.
Shoe size should be checked as follows:
| Age: | 1-6 Years 6-10 Years 10-12 Years 12-15 Years 15-20 Years >20 Years |
Check Shoe Fit: | Every 2 months Every 3 months Every 4 months Every 5 months Every 6 months Every new shoe purchase |
The Footwear Council offers the following fitting tips:
- If your child is repeatedly removing their shoes, the shoes may be too small.
- Any sign of a limp could mean trouble and shoes must be checked.
- If the shoe lining shows excessive wear in the area of the fifth toe, the shoes are too short. You can feel the inside lining of the shoe for dents for improper toe pressure.
- Watch for any red marks across the top of the foot, over the tops of the toe, or on the sides of the foot. When present, the shoe is likely too narrow or too small.
- If the soles are unevenly worn with excessive wear on the inside or outside edges this could be an indication of improper foot/ankle function. The child should be taken to see a specialist who can determine the best type of treatment to correct this.
Finally, remember that choosing a shoe for a child is a short-lived activity since they will soon insist on choosing shoes for themselves.
Common Pediatric Foot Conditions
We describe below the most common foot problems seen in NEFAS's pediatric patient population. Additional information may be found on our website at www.painfreefeet.com.
Pediatric Flatfoot
To treat or not to treat a pediatric flatfoot has been debated over the past many decades. Some feel that children will outgrow the condition, while others contend that treating the deformity early can prevent the long-term complications we see all too often in adults. I believe this decision should not be made by anyone without seeing a pediatric foot specialist first.
Parents often express concern regarding their child's apparent flattened foot (i.e., no clear visible arch when standing). The fact is nearly all children have flat feet (or pes planus) at some point in their development. Between 9 and 18 months, when a child begins to walk, the foot appears chubby and therefore flat. A normal fat pad consumes what will someday be the arch as the child develops. So at this age, a flatfoot is considered normal.
At 2 to 4 years of age, the foot takes on a more bony appearance as the fat pad disappears allowing a flatfoot to become more noticeable. The foot remains quite pliable at this stage as the bones are not fully developed. The abnormal forces caused by a flatfoot may cause permanent structural damage to the foot. The inside of the arch becomes flattened, the ankles appear to be rolling inward, and the front part of the foot appears to point outward causing some instability during walking. The child tends to complain of pain in the arch, heel or ankle, as well as cramping in the legs. They may even trip or stumble over their own feet. These symptoms worsen with excessive standing, walking or running, and may lead to the child compensating in other ways to avoid the discomfort. For example, your child may refuse to participate in sports or claim he is too tired (even though he seems to have boundless energy at home).
There are generally two types of pediatric flatfoot. A Flexible flatfoot is more common and often associated with overuse injuries in child athletes. There is an appreciable arch non-weightbearing that fully collapses on stance. A Rigid flatfoot is less common and is usually due to abnormal bone structure or growth during development (see Tarsal Coalition). A rigid flatfoot is always stiff and flat no matter the weightbearing status.
Regardless of flatfoot type, children with collapsing arches should be evaluated by a podiatrist at least annually to prevent problems. X-rays can be obtained to determine how the bones are developing, gait analysis can determine if the problem is isolated to the foot or stemming from a more proximal location, and shoe wear evaluation can guide you to more appropriate shoes and activities as necessary. We have in office digital x-ray at Northeast Foot & Ankle Specialists, PC.
The simple presence of a flatfoot deformity does not necessarily require treatment. However, if another family member has had difficulties with such a deformity in their past, then treating the child is good preventative medicine.
In asymptomatic flat feetfoot, no treatment is needed unless the foot is deemed pathological by the specialist. A good sturdy shoe is all that may be needed if not pathologic. Secondary symptoms of "Charlie horses" or leg cramps, tired feet, and knee and hip pain may require special shoe inserts (Orthotics/Arch Supports) to promote a healthy gait.
In painful or pathologic flatfoot, treatment is necessary. Activity modification, new shoe gear, stretching exercises, anti-inflammatories and arch supports are the mainstay of therapy. Many times, significant deformities require custom functional orthotics and physical therapy for more aggressive symptomatic relief but this may not correct the proble,. There is a high incidence of painful flatfoot in an obese child as the weight overloads the developing feet. Weight loss is always recommended prior to surgery in these cases.
Surgery is now a viable option if the child is having consistent difficulty in weightbearing activities, has undergone at least 6 months of aggressive conservative therapy and has a significant deformity without improvement. Surgical procedures used to treat severe flatfoot include tendon transfer or lengthening, realignment of one or more bones, joint fusion, and/or placement of a subtalar stent. Surgical procedures are patient dependant and can be a combination of the aforementioned.
At NEFAS we use the HyProCureTM subtalar stent which is a small device that is inserted into the canalis tarsi, a canal that is positioned above the calcaneus (heel bone) and below the talus (the bottom bone of the ankle). The implant acts as an "internal orthotic" and restores the arch of the foot instantly. The procedure takes 15 minutes, is minimally invasive and requires little downtime. This is often our preferred procedure when possible for the following reasons: (1) small incision with minimal change in cosmesis, (2) reversible - implant can be removed with minimal to no residual effects, (3) allows for immediate weightbearing, and (4) typically performed in under 15 minutes thereby limiting anesthesia exposure. You can visit www.painfreefeet.com to see examples of these procedures before and after.
In-toeing
If your child walks with their toes pointed inward, they are in-toeing or considered to be pigeon-toed. In-toeing is a part of normal development in children and will not affect their ability to walk, run or play. Some sports experts have even suggested that sprinters may have an advantage by being in-toed. In-toeing is usually seen in both feet, but may affect one side more than the other. Occasionally the deformity is severe enough to cause pain, shoe irritation and tripping, and it can predispose a foot to have other problems. Social concerns are also valid due to the "bully" attitude on the playground.
At first glance, it might seem like in-toeing is a deformity of the foot, however it can be the result of any rotational over-growth or under-growth at any bone or joint from the foot up to the hip. For example, a common cause of in-toeing in children under 2 years of age is not enough tibial torsion. The main bone in the lower leg (tibia/shin bone) has a normal growth development that includes a twisting of the leg in an outward direction. If this does not undergo its full rotation, a child can have a foot that appears in-toed. If the leg rotates too much, then the reverse effect will result in an out-toed position of the foot.
The most common cause of in-toeing among children between the ages of 2-10 years is excessive inward twisting of the bone in the upper leg (femur/thigh bone). This is referred to as femoral anteversion. The hip joint undergoes rotational changes in an inward direction through adolescence. If the femur is twisted inward too much, the knees and toes will follow. Children with a twisted femur often sit with their legs crossed. Fortunately, most children will slowly grow out of this deformity.
Another reason a child may have an in-toed gait is due to a deformity in the foot itself. If your child's foot appears to be curved inward exhibiting a "C-shape," metatarsus adductus or hallux varus may be the reason. Either the metatarsal (long bones to the toes) or the hallux (big toe) can be pointing inward. Metatarsus adductus is one of the most common pedal deformities occurring in 1-2/1,000 births. These deformities will usually be seen at birth, but can appear to worsen with time.
It is good to evaluate metatarsus adductus prior to a child's walking because conservative treatment options decrease with age. If it is very mild, the parents may be shown how to rub the outside of the foot to help the foot to go straight. Some children may need to wear special shoes. If the foot is rigid and cannot be straightened, it may be necessary to put casts on the feet and lower legs. The casts are usually put on before 8 months of age. If the foot has not straightened by the time a child is walking, the child may walk with his toes pointing in. In older children, if these treatments are not satisfactory, surgery may be indicated.
In-toeing is not a diagnosis, but a complaint and an objective finding on physical examination. Because the development of the child's leg and foot is a gradual process, it is not uncommon for a doctor to tell a parent: "Your child will grow out of it". While most of the time this is true, typically by the age of 8, there are occasions when the deformity does not correct itself. Early detection and close monitoring will increase the treatment options and improve outcomes.
Toe Walking
It is not uncommon for early walkers to walk on their toes as their muscles learn the correct way to balance the body. Most children between 1-2 years of age will experiment by walking on their toes, but this is generally short-lived. By age 3 children should begin walking with a more normal heel-to-toe walking pattern. If your child continues to toe walk, you should ask your podiatrist for a more detailed physical exam.
Equinus is the medical term for toe-walking and is defined as a foot that does not have enough dorsiflexion (i.e., flexion at the ankle joint bringing the foot toward the front of the leg). Occasional toe-walking is not a concern, especially if the child can voluntarily bring the heel to the ground. However, the child should be evaluated to rule out any neurological causes of the condition, especially if it becomes persistent.
There are three main reasons why a child may toe-walk. First, and most importantly, it may be caused by a spasticity of the calf muscles (gastrocnemius and soleus muscles). This is due to a neurological problem such as cerebral palsy, the most serious concern for toe-walking. The second most common reason for toe-walking is due to a tight heel cord (Achilles tendon). This can be treated with stretching, bracing, casting and sometimes surgery if indicated. The third reason is habitual toe-walking. For some reason children may just prefer to walk on their toes. They can walk on their heels when asked, but prefer to toe-walk. This is best treated with clever parenting and encouragement of heel walking.
Left untreated, toe walking can cause the bones to grow incorrectly and/or overstretch ligaments - putting your child at risk for injuries and joint pain as they grow older. Toe walking takes more energy than regular walking thereby leaving a child tired, unable to keep up with friends and unable to fully participate in sports. Moreover, shoes can be difficult to fit or may cause irritation with walking.
Depending on the underlying cause of your child's toe walking, physical therapy and/or serial casting may be beneficial. In some cases a lengthening of the tendon performed endoscopically called EGR or Endoscopic Gastrocnemius Recession can be performed to given permanent correction. This is a minimally invasive procedure.
Juvenile Bunion
As with bunions in adults, in juvenile bunion, the joint at the base of the big toe (the metatarsophalangeal joint) moves out of alignment in such a way that the big toe angles inward toward the second toe. Unlike adult bunions, which usually result from ill-fitting footwear, injury to the joint, or have a hereditary component, juvenile bunion occurs most often in children who are ligamentously lax or loose-jointed - more frequent in girls.
Surgical treatment for juvenile bunion is necessary but delayed if possible until the end (or close to the end) of growth, both because of concern for damage to the growth plate and because the condition tends to recur if treated too early. Non-operative treatment includes the use of wide shoes and avoidance of narrow dress shoes and high heels. Usually this sufficiently alleviates symptoms until the patient can have surgical correction. Almost all juvenile bunions need surgery.
In younger patients who do not respond to non-operative treatment and who have pain that interferes with their daily activities, surgery to realign the bone and straighten the toe can be performed. A number of different approaches are used, depending on the type of bunion, the extent of the deformity, the age of the child, and how much growth remains.
Tarsal Coalition
Tarsal coalition is not a problem you as a parent will recognize as there is no specific deformity to the naked eye. Children with tarsal coalition develop an abnormal connection between the bones in the midsection and back part of the foot. It is usually diagnosed in late childhood or early adolescence when the coalition begins to limit foot movement, causing pain and stiffness. Symptoms may be particularly noticeable when walking on uneven surfaces, such as sand or gravel, an action that requires constant adjustment and adaptation of the foot. Frequent ankle sprains may also signal the presence of a coalition.
Most tarsal coalitions may be classified as one of two types: a calcaneonavicular coalition, in which the tissue develops between the calcaneus (heel bone) and the navicular (one of the foot bones), or a talocalcaneal or subtalar coalition, in which the coalition develops between the calcaneus and the talus (the ankle bone). The coalition may be composed exclusively of bone, a combination of bone and cartilage, or even fibrous tissue. Tarsal coalitions occur in both feet in about half of all cases.
Initial treatment for tarsal coalition is conservative starting with rest or immobilization. Although pain relief can be achieved in this way, in many cases the result is only temporary. Non-operative treatment can be appropriate for patients with tarsal coalitions that are symptom-free, and whose condition only becomes apparent on x-ray taken incidentally for another condition, such as an acute ankle sprain. A CAT scan or MRI is often needed to fully evaluate this condition.
For children with ongoing pain, who do not respond to conservative non-operative measures, a podiatrist may remove the coalition. In most cases another type of tissue - usually fat - is placed between the bones to prevent the coalition from growing back. Tarsal coalitions may also be associated with other foot deformities, most commonly a flatfoot deformity, which may require treatment as well.
