Pediatric & Lower Extremity Injuries

Pediatric Flatfoot

What Is Pediatric Flatfoot?

normal pediatric foot vs flatfoot sketch

Flatfoot is common in both children and adults. When this deformity occurs in children, it is referred to as pediatric flatfoot. Although there are various forms of flatfoot, they all share one characteristic—partial or total collapse of the arch.

Pediatric flatfoot can be classified as symptomatic or asymptomatic. Symptomatic flatfeet exhibit symptoms, such as pain and limitation of activity, while asymptomatic flatfeet show no symptoms. These classifications can assist your foot and ankle surgeon in determining an appropriate treatment plan.

Symptoms

Flatfoot can be apparent at birth or it may not show up until years later. Most children with flatfoot have no symptoms, but some have one or more of the following symptoms:

  • 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
Diagnosis

In diagnosing flatfoot, the foot and ankle surgeon examines the foot and observes how it looks when the child stands and sits. The surgeon observes how the child walks and also evaluates 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 deformity’s severity. Sometimes additional imaging and other tests are ordered.

pediatric flatfoot diagnosis sketch

pediatric flatfoot back view

Nonsurgical Treatment

If a child has no symptoms, treatment is often not required. Instead, the condition will be observed and reevaluated periodically by the foot and ankle surgeon.

Custom orthotic devices may be considered for some cases of asymptomatic flatfoot.

When the child has symptoms, treatment is required. The foot and ankle surgeon may select one or more of the following nonsurgical approaches:

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. Nonsteroidal 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. The surgical procedure or combination of procedures selected for your child will depend on his or her type of flatfoot and degree of deformity.

Calcaneal Apophysitis (Sever’s Disease)

What Is Calcaneal Apophysitis?

Calcaneal apophysitis is a painful inflammation of the heel’s growth plate. It typically affects children between the ages of 8 and 14 years old, because the heel bone (calcaneus) is not fully developed until at least age 14. Until then, new bone is forming at the growth plate (physis), a weak area located at the back of the heel. When there is too much repetitive stress on the growth plate, inflammation can develop.

Calcaneal Apophysitis Sketch

Calcaneal apophysitis is also called Sever’s disease, although it is not a true “disease.” It is the most common cause of heel pain in children, and can occur in one or both feet.

Heel pain in children differs from the most common type of heel pain experienced by adults. While heel pain in adults usually subsides after a period of walking, pediatric heel pain generally doesn’t improve in this manner. In fact, walking typically makes the pain worse.

Causes

Overuse and stress on the heel bone through participation in sports is a major cause of calcaneal apophysitis. The heel’s growth plate is sensitive to repeated running and pounding on hard surfaces, resulting in muscle strain and inflamed tissue. For this reason, children and adolescents involved in soccer, track, or basketball are especially vulnerable.

Other potential causes of calcaneal apophysitis include obesity, a tight Achilles tendon, and biomechanical problems such as flatfoot or a high-arched foot.

Symptoms

Symptoms of calcaneal apophysitis may include:

  • Pain in the back or bottom of the heel
  • Limping
  • Walking on toes
  • Difficulty running, jumping, or participating in usual activities or sports
  • Pain when the sides of the heel are squeezed
  • Tiredness
Diagnosis

To diagnose the cause of the child’s heel pain and rule out other more serious conditions, the foot and ankle surgeon obtains a thorough medical history and asks questions about recent activities. The surgeon will also examine the child’s foot and leg. X-rays are often used to evaluate the condition. Other advanced imaging studies and laboratory tests may also be ordered.

Treatment

The surgeon may select one or more of the following options to treat calcaneal apophysitis:

Reduce activity. The child needs to reduce or stop any activity that causes pain.

Support the heel. Temporary shoe inserts or custom orthotic devices may provide support for the heel.
Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation.

Physical therapy. Stretching or physical therapy modalities are sometimes used to promote healing of the inflamed issue.

Immobilization. In some severe cases of pediatric heel pain, a cast may be used to promote healing while keeping the foot and ankle totally immobile.

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 calcaneal apophysitis, or it may indicate a different problem. If your child has a repeat bout of heel pain, be sure to make an appointment with Dr. Cottom at 941.924.8777

Can Calcaneal Apophysitis Be Prevented?

The chances of a child developing heel pain can be reduced by:

  • Avoiding obesity
  • Choosing well-constructed, supportive shoes that are appropriate for the child’s activity
  • Avoiding or limiting wearing of cleated athletic shoes
  • Avoiding activity beyond a child’s ability

Intoeing

Intoeing (pigeon toes) is a condition in which the feet point inward when walking. It is commonly seen in children and may resolve in very early childhood with no treatment or intervention.  The child should be examined by a foot and ankle surgeon if the intoeing is causing significant tripping, difficulty with normal activity, pain, difficulty with shoes or is not resolved in early childhood. Structural problems may be causing the intoeing, which require treatment by Dr. Cottom.

Toe Walking

Toe walking, a condition in which a person walks on the toes or ball of the foot, is most often seen in young children learning to walk. A child who does not outgrow toe walking in early childhood should be evaluated by a foot and ankle surgeon. Toe walking may be idiopathic (habitual) or it can be caused by a shortened Achilles tendon (equinus deformity) often associated with a neurological or muscular disorder.

Accessory Navicular Syndrome

What Is Accessory Navicular?

Accessory Navicular Syndrome Sketch

The accessory navicular (os navicularum or os tibiale externum) is an extra bone or piece of cartilage located on the inner side of the foot just above the arch. It is incorporated within the posterior tibial tendon, which attaches in this area.

An accessory navicular is congenital (present at birth). It is not part of normal bone structure and therefore is not present in most people.

What Is Accessory Navicular Syndrome?

People who have an accessory navicular often are unaware of the condition if it causes no problems. However, some people with this extra bone develop a painful condition known as accessory navicular syndrome when the bone and/or posterior tibial tendon are aggravated.

This can result from any of the following:

  • Trauma, as in a foot or ankle sprain
  • Chronic irritation from shoes or other footwear rubbing against the extra bone
  • Excessive activity or overuse

Many people with accessory navicular syndrome also have flat feet (fallen arches). Having a flat foot puts more strain on the posterior tibial tendon, which can produce inflammation or irritation of the accessory navicular.

Signs & Symptoms of Accessory Navicular Syndrome

Adolescence is a common time for the symptoms to first appear. This is a time when bones are maturing and cartilage is developing into bone. Sometimes, however, the symptoms do not occur until adulthood.

The signs and symptoms of accessory navicular syndrome include:

  • A visible bony prominence on the midfoot (the inner side of the foot, just above the arch)
  • Redness and swelling of the bony prominence
  • Vague pain or throbbing in the midfoot and arch, usually occurring during or after periods of activity
Diagnosis

Accessory Navicular Syndrome Diagnosis Sketch

To diagnose accessory navicular syndrome, the foot and ankle surgeon will ask about symptoms and examine the foot, looking for skin irritation or swelling. The doctor may press on the bony prominence to assess the area for discomfort. Foot structure, muscle strength, joint motion and the way the patient walks may also be evaluated.

X-rays are usually ordered to confirm the diagnosis. If there is ongoing pain or inflammation, an MRI or other advanced imaging tests may be used to further evaluate the condition.

Nonsurgical Treatment Approaches

The goal of nonsurgical treatment for accessory navicular syndrome is to relieve the symptoms.

The following may be used:

Immobilization. Placing the foot in a cast or removable walking boot allows the affected area to rest and decreases the inflammation.

Ice. To reduce swelling, a bag of ice covered with a thin towel is applied to the affected area. Do not put ice directly on the skin.

Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be prescribed. In some cases, oral or injected steroid medications may be used in combination with immobilization to reduce pain and inflammation.

Physical therapy. Physical therapy may be prescribed, including exercises and treatments to strengthen the muscles and decrease inflammation. The exercises may also help prevent recurrence of the symptoms.

Orthotic devices. Custom orthotic devices that fit into the shoe provide support for the arch and may play a role in preventing future symptoms.

Even after successful treatment, the symptoms of accessory navicular syndrome sometimes reappear.  When this happens, nonsurgical approaches are usually repeated.

When Is Surgery Needed?

If nonsurgical treatment fails to relieve the symptoms of accessory navicular syndrome, surgery may be appropriate. Surgery may involve removing the accessory bone, reshaping the area and repairing the posterior tibial tendon to improve its function. This extra bone is not needed for normal foot function.

Tarsal Coalition

What Is a Tarsal Coalition?

A tarsal coalition is an abnormal connection that develops between two bones in the back of the foot (the tarsal bones). This abnormal connection, which can be composed of bone, cartilage or fibrous tissue, may lead to limited motion and pain in one or both feet.

Tarsal Coalition Sketch

The tarsal bones include the calcaneus (heel bone), talus, navicular, cuboid and cuneiform bones. These bones work together to provide the motion necessary for normal foot function.

Causes

Most often, tarsal coalition occurs during fetal development, resulting in the individual bones not forming properly. Less common causes of tarsal coalition include infection, arthritis or a previous injury to the area.

Symptoms

While many people who have a tarsal coalition are born with this condition, the symptoms generally do not appear until the bones begin to mature, usually around ages 9 to 16. Sometimes no symptoms are present during childhood. However, pain and symptoms may develop later in life.

The symptoms of tarsal coalition may include one or more of the following:

  • Pain (mild to severe) when walking or standing
  • Tired or fatigued legs
  • Muscle spasms in the leg, causing the foot to turn outward when walking
  • Flatfoot (in one or both feet)
  • Walking with a limp
  • Stiffness of the foot and ankle
Diagnosis

A tarsal coalition is difficult to identify until a child’s bones begin to mature. It is sometimes not discovered until adulthood. Diagnosis includes obtaining information about the duration and development of the symptoms as well as a thorough examination of the foot and ankle. The findings of this examination will differ according to the severity and location of the coalition.

In addition to examining the foot, the surgeon will order x-rays. Advanced imaging studies may also be required to fully evaluate the condition.

Nonsurgical Treatment

The goal of nonsurgical treatment of tarsal coalition is to relieve the symptoms and to reduce the motion at the affected joint.

One or more of the following options may be used, depending on the severity of the condition and the response to treatment:

Oral medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be helpful in reducing the pain and inflammation.

Physical therapy. Physical therapy may include massage, range-of-motion exercises and ultrasound therapy.
Steroid injections. An injection of cortisone into the affected joint reduces the inflammation and pain. Sometimes more than one injection is necessary.

Orthotic devices. Custom orthotic devices can be beneficial in distributing weight away from the joint, limiting motion at the joint and relieving pain.

Immobilization. Sometimes the foot is immobilized to give the affected area a rest. The foot is placed in a cast or cast boot, and crutches are used to avoid placing weight on the foot.
Injection of an anesthetic agent. Injection of an anesthetic into the leg may be used to relax spasms and is often performed prior to immobilization.

When Is Surgery Needed?

If the patient’s symptoms are not adequately relieved with nonsurgical treatment, surgery is an option. Dr. Cottom will determine the best surgical approach based the patient’s age, condition, arthritic changes and activity level.