Foot & Ankle Conditions (Pediatric)

Introduction

  • Tip Toe Walking is common in the first year or two of ambulation. After which time, it should resolve. Some children have a tightness in their Achilles that predisposes them to continue walking on their tip toes. Eventually, this can lead to problems such as leg and foot pain. If clinical evaluation rules out neurologic causes, it is considered idiopathic. Idiopathic tip toe walking is treated with stretching exercises, use of night time splints, or serial casting. Some refractory cases require surgery.
  • Flatfeet: Nearly all toddlers have “collapsed arches” upon standing causing the ankles to roll in and the feet to out-toe. A flexible flatfoot is considered a variation of normal in which the arch reappears when the child sits or goes up on his/her tiptoes. Often familial and more common in children with ligamentous laxity, the flexible flatfoot is usually painless and causes no functional impairment with walking or sports. The arch begins to elevate spontaneously by age 5 and adopts the adult position by age 10. However, up to 20% of children do not outgrow the flatfoot and it will persist into adulthood. Less commonly, the flatfoot may be rigid. X-rays, and sometimes a CT or MRI, are necessary to evaluate the possibility of congenital anomalies of the bones, called tarsal coalitions, as this may require surgical intervention. Whereas use of orthotics, shoe inserts, or special orthopedic shoes has NOT been shown to create an arch, such devices may alleviate arch pain or fatigue pains in the leg when present. The status of the patient’s Achilles tendon cannot be over-emphasized because children and adolescents with flatfeet AND a tight Achilles are prone to developing pain and disability. The Achilles has the potential to tighten during periods of rapid growth, hence the importance of routine stretching. The Achilles tendon is actually made up of 2 muscles; the gastrocnemius and the soleus. The former begins above the knee and the latter begins below the knee. Proper stretching of the Achilles tendon requires maintaining the knee in a straight position (bending the knee does not allow proper stretch of the gastrocnemius and it is this muscle that is often selectively tight in growing children). Pain and poor activity-related endurance often improves once the Achilles is properly stretched. Surgical intervention is the only method that can create an arch.
  • Tarsal Coalitions are abnormal connections of bones in the foot. This condition can lead to a stiff and painful foot. Whereas these are present at birth, symptoms may not develop until the child is older. X-rays and advanced imaging studies such as CT and/or MRI are frequency necessary to evaluate tarsal coalitions. Persistently symptoms may warrant surgical excision.
  • Accessory Navicular is an extra bone on the instep of the foot that can cause pain with activities. Whereas these are considered an anatomic variation, only some children, typically in the pre-adolescent years, will develop pain. Rest, anti-inflammatory medications, and immobilization with a boot or cast may help alleviate associated pain. Surgery is considered only for persistently painful conditions.
  • Curly Toes are common in infants and toddlers. They cause the third and sometimes fourth toe to curl under the second and third toe, respectively. If wearing of shoes causes symptoms, surgery to release a tight flexor tendon may be necessary.
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