Parents are often concerned about the appearance of a child’s feet and specifically whether flatfeet might be present. When children begin walking, it appears that many have flatfeet because of increased fat deposits in the arch. As a child grows, it becomes apparent that, in most instances, the feet are not flat at all; an arch becomes evident by age ten. There is little justification for prescribing expensive “orthopedic” shoes or custom-molded inserts, since there is no proof that they help to correct flatfeet. Similarly there is no evidence that high-top shoes are better for a child with flatfeet than low-cut shoes.
Children with obvious flatfeet may develop aching in their feet, particularly when they have been on them for much of the day. In such cases it may be helpfu1 to provide a support within the shoe. For some, a good pair of running shoes with an arch support already in place will be adequate. For others a custom-molded insert may be helpful in providing relief. Surgery is needed only very rarely to treat flatfeet and is usually reserved for severe cases that have not responded to simpler measures. Before agreeing to such surgery, a second and possibly even a third opinion should be sought. At least one of the consultants should be an orthopedic surgeon with a lot of experience treating children’s feet.
Banana Foot (Calcaneovalgus)
This is a common deformity found at birth. The top of the foot lies directly against the front of the leg. This occurs as a result of positioning within the uterus, and in 90 percent of cases involves both feet. Fortunately the deformity starts to correct spontaneously after delivery, and gentle stretching can help speed up the correction. These children often walk with their feet pointing out, or turned out more than normal. This will usually correct without treatment.
Curved Foot (Metatarsus Adductus)
This deformity is common at birth and often mistakenly called clubfoot, but it does not have all the features of clubfoot and generally causes fewer problems. The curved shape of the foot spontaneously corrects itself in85 to 90 percent of cases, and because of this, treatment is deferred until the age of three months. Treatment of a persistent deformity usually involves stretching and casting or using special braces or shoes. In very few cases will the deformity persist or be severe enough to warrant surgery. Occasionally there is an association between metatarsus adductus and hip dysplasia.
Clubfoot is a deformity easily recognized in newborns, but the cause is unknown in most cases. The severity of the deformity can range from a very flexible club-foot to one that is very rigid. Most fit somewhere in between. The affected foot will be smaller than normal; the calf above the clubfoot will often be significantly smaller, and the entire leg slightly shorter than normal. These differences will continue throughout the child’s growth process. Treatment should be started as soon as possible by a physician who has a lot of experience treating clubfeet. The initial treatment includes frequent stretching of the foot by the physician followed lowed by the application of a cast. In some instances the deformity will be corrected, and the casting will he replaced by bracing or special shoes for several months. Eventually the child can wear regular shoes and should be checked regularly as he grows.
In a significant number of cases, the clubfoot will not completely correct with stretching and casting, and surgery will he recommended—some may even require multiple surgeries. Surgical correction in most cases results in nearly normal function of the foot, although some stiffness and discomfort may occur, especially after vigorous activity.
High-Arched Foot (Cavus)
This condition may be an indication of an underlying disease. If your child’s feet appear normal during childhood but develop high arches in later childhood or adolescence, have him assessed by a physician, who will look carefully for evidence of a neurologic problem.
Bunions (Hallux Valgus)
Bunions can occur in older children and adolescents. Often the appearance of the deformity and the pain that accompanies it bring an adolescent to the doctor. In some cases finding shoes that are wide enough to fit comfortably is difficult. Occasionally, a foot orthotic (such as an arch support) may help slow down the deformity’s development, but usually acceptable correction is achieved only through surgery. While surgery is successful much of the time, sometimes subsequent surgeries become necessary. If pain is tolerable and appropriate footwear can be found, it is best to postpone surgery as long as possible. There is a very high recurrence rate after surgery for this deformity in an adolescent. The likelihood of recurrence declines as the adolescent becomes an adult.
Often seen in very active children, heel pain probably represents an “overuse “syndrome. One of the most common causes is Sever’s disease, which occurs where the Achilles tendon attaches to the heel bone. The heel is often quite tender to the touch at this site. In most instances, restricting activities that cause the greatest discomfort, as well as an exercise program to stretch the heel cord, and heel cups added inside the shoes, are of greatest benefit. Icing the heel before and after activity can also help. Very rarely is it necessary to immobilize the leg in a cast. Surgery does not help this problem. In most cases this condition disappears on its own in ten to twelve weeks.
Knee Pain and Disorders
Knee pain is a common complaint in children and adolescents. A number of things can cause this, including significant hip problems that produce pain near knee. Most often pain in knee occurs during activity rather than when the knee is at rest.
Pain in the region of the kneecap is very common in teenage girls, although the underlying cause is often not clear. Frequently the best approach is to start program focusing on the thigh-muscles (quadriceps).
An extremely tender area, often with an obvious bump, may be present about an inch below kneecap where the large tendon from the kneecap attaches to the shinbone. This condition is known as Osgood Schlatter’s disease and is similar to Sever’s disease of the heel. It is best treated by rest, application of ice packs, ibuprofen, thigh exercises, and, rarely, immobilization. This condition usually resolves on its own as the child passes through adolescence.
A condition called osteochondritis dissecans, which produces a softening of bone under the cartilage, can cause pain deep within the knee. With reactions to running and jumping activities, this condition usually heals slowly on its own. Occasionally, the affected area of bone and/or cartilage separates completely from the rest of the bone and requires surgery.
If your child complains of a sore swollen knee, has no history of injury, and the symptoms persist for several weeks without improvement, he may have juvenile rheumatoid arthritis.
As children grow, their legs usually progressively change in shape. Toddlers most commonly are quite bowlegged. Between the ages of two and eight, children typically appear knock-kneed and may become more so during this period. After the age of eight, the legs gradually become straighter, although they don’t always correct completely.
If your child’s legs seem excessively crooked and don’t seem to be following the basic pattern described above, it is important that you consult your child’s doctor. Occasionally, severe bowlegs or knock-knees are signs of underlying disease. Leg braces have not proven very effective in correcting these deformities, and surgery becomes necessary in some cases.
In-Toeing, Out-Toeing, and Toe-Walking
A common reason for a child to he brought to an orthopedic surgeon is to be evaluated for in-toeing (or a pigeon-toed appearance of the feet), which occurs in 10 percent of children between the ages of two and five. The complaint most frequently expressed by parents is that the child seems to trip and fall a lot.
The source of in-toeing varies. Younger children may have a curved deformity of their feet that gives the appearance of in-toeing. Children most commonly in-toe because they have a torsion or twist in the tibia (shinbone) or the femur (thighbone) or sometimes both. Torsion of the tibia is usually responsible for in-toeing in a child younger than age two or three. If the problem begins when the child is over age three, the location of the torsion is more often in the femur.
Most in-toeing will correct on its own. A slight degree of persistent in-toeing is not a serious problem. (Some of the fastest runners in the world have this condition.) There is no clear evidence that persistent in-toeing leads to increased incidence of degenerative arthritis in the hip in adulthood. Several methods have been used in children to try to correct torsional problems, including wedges on the sides of the shoes, braces, various night splints, and casting. There is little evidence that any of these methods directly improves the degree of in-toeing.
Many children toe out when they start to stand. In most children this condition will also correct itself in time. A persistent out-toeing deformity is much less common than in-toeing. If the problem is severe, it may require corrective surgery.
Occasionally a child will continue toe-walking (walking on tiptoes, which is often seen when a toddler is learning to walk) through the first few years of life or even later into the school years. This usually results from one of the following:
- A persistent habit, which can be altered by having the child practice a normal gait
- Congenital tight heel cords, which may need gentle stretching
- Cerebral palsy, in which case other manifestations of this disorder will be present as well
If your child toe-walks all or most of the time, your physician or an orthotic can evaluate his gait and recommend an appropriate approach for correcting it.
Children commonly experience growing pains. A typical scenario is that of a healthy five-year-old who is very active during the day and has no noticeable problems. He goes to bed but sometime later awakens, screaming about pain in his leg or occasionally in both. (The pain might develop before he falls asleep.) There is no history of injury, and the child is not sick. The parents do what they can—rubbing the leg, applying heat, giving him a warm bath or a pain reliever—and in 30 to 60 minutes the pain resolves and the child goes back to sleep. In the morning it appears that nothing has happened. There is no pain, limp, or any further evidence of a problem. This may recur frequently, at which point the child’s taken to the doctor, who can find absolutely nothing wrong with him. Their physician says the child has growing pains.
Nobody really knows what causes these pains, nor does there appear to be any way to prevent them. The pain is reasonably short-lived, and there are no long-term consequences. The best advice is to be patient because the pains will eventually stop.
On the other hand, if a child screams with pain at night and then limps and complains of pain during the day, he needs to be evaluated by a physician.
A physician may uncover some form of unstable hip in an infant shortly after birth. If the hip is completely out of place, it is dislocated. Sometimes the hip is in its proper position, but with a little pressure it can be moved outof joint and then back into place. This hip is called dislocatable. In other instances, the hip-joint socket is too shallow, in which case the hip is called dysplastic.
The most serious infant hip problem is a dislocated hip, which should be diagnosed and treated as soon as possible. Generally a splint, harness, or cast will be required for several weeks, with frequent progress checks by the physician.
The most common problem is a dislocatable hip. In many cases, it corrects itself within a few days. If the problem is detected at birth, the physician may de-cide to use some form of splint, harness, or brace to hold the hips in the best position for healing. In most cases, the hip will eventually develop normally.
A dysplastic hip can be extremely difficult to diagnose, even in the most experienced hands. It may become apparent only after the hip eventually dislocates. In slider forms it may not become apparent for many years and then manifest itself as a painful hip with early arthritis.
Some babies’ hips will appear normal during the examination at birth but will later dislocate. You may notice when changing the baby’s diaper that you cannot spread one leg as far as the other. This should be pointed out to the doctor. An X-ray or sonogram will probably be performed and if a dislocated hip is found, treatment will begin.
Occasionally a dislocated hip will not be diagnosed until the child be-gins to walk. The child may be observed walking on tiptoes on one leg, which will appear shorter than the other. See a doctor immediately; an X-ray will probably be taken. The older the child is before the diagnosis is made, the more likely that surgery will be required to replace the hip back in the socket.
This occurs in children as young as eighteen months and as old as fourteen years of age, with a peak incidence between ages four and seven. The condition develops when, for reasons that are uncertain, the blood supply to the ball-shaped head of the femur (thighbone) is interrupted. As a result, part or all of the head of the femur dies. At first there may be little or no indication of this. Over time, however, the hip will begin to hurt, causing the child to limp and decrease movement of the hip joint. An X-ray of the hip usually confirms the diagnosis.
While the body is removing the dead bone and replacing it with new live bone, the tissue at the head of the femur is somewhat soft and pliable. This tissue can become deformed, and if uncorrected, the deformity can become permanent as the soft tissue transforms to bone.
Once Legg-Calve-Perthes Disease is diagnosed, treatment focuses on keeping the ball of the femur positioned properly in the hip socket and moving the hip as much as possible to help mold the pliable tissue into the appropriate round shape. Casting, bracing, exercise, and surgery may be used.
Slipped Capital Femoral Epiphysis
This most commonly occurs in overweight teenage boys, but it can occur in girls as well. The ball of the hip joint gradually slides off the neck of the femur (thighbone) and through the growth plate. The child will begin to experience groin pain or sometimes knee pain, which worsens with activity. One foot may turn out more than the other when the child walks. Diagnosis and treatment must be carried out as early as possible. If there are delays, the ball of the hip may slide further off the neck, making the prognosis worse. Sometimes a fall causes further slip, in which case pain is usually more severe. In either case, surgical treatment is necessary.
From time to time, a child may complain that an arm or leg hurts and then become absorbed in play without any apparent discomfort. If so, it is reasonable to wait and watch for further reports of pain. However, any complaint about pain in a particular area that lasts for more than a day or two should be investigated by a physician. In a child of any age a limp or unwillingness to walk because of leg pain may indicate a significant problem and should be reported to the doctor immediately.