Children's Foot Problems
When a child complains of foot or ankle pain, special attention needs to be paid to ascertain its severity. The most common problems in the growing foot are poorly developing arches, common ingrown nails, childhood warts on the feet and hands and injuries potentially causing damage to growth plates.
Normal arch development
It is normal for a child to develop an arch by age six. Prior to age six a painless flatfoot usually represents normal development. As early as age seven or eight, if flatfoot conditions are inherited from mom or dad, children may complain of foot pain after walking around Disneyland or following soccer or ballet lessons. The molded shoe insert made to support a child's foot may be different from that for an adult. A child that has had orthotics growing up should be ready for their permanent adult pair by age 14 for girls and 16 for boys. Will orthotics make my child develop an arch? Usually if a child does not develop an arch, the resultant flat foot is usually associated with a tight Achilles tendon. This can be addressed non-surgically by loosening of the tendon with the use of a comfortable splint worn for 30 to 60 minutes in the evening while doing homework or watching TV. Correct positioning of the 27 foot bones can then be maintained during the day with a comfortable molded shoe insert that is left in the bottom of the child's shoes.
Children are prone to hand and foot warts usually as they near adolescence. On the hand they can be readily frozen off but on the bottom of the foot it can be a different story. The skin on the bottom of the foot is the thickest anywhere on the body and the freezing treatments don't always penetrate to the right level. Occasionally freezing plantar warts in children will make them spread. Generally, to get rid of warts everyone in the family should be treated at the same time. Warts are caused by a virus with 30 different subtypes.
Ingrown nails have long been thought to be caused by trimming the nail to closely or not trimming it straight across. While it is true that if you trim down into a nail edge and leave a sharp spicule this may cause an ingrown nail, it is usually the case that the cause is hereditary. The procedure to permanently correct the condition removes just the edge of the nail that is ingrown leaving a normal appearing nail. Postoperatively some soaking and band aids are required and rarely is school missed. The same procedure is done in adults. If accompanied by infection then antibiotics are used as necessary and the permanent nail procedure can usually be done at the same time that the infection is cleared out. What about children who are afraid of needles? Pretreatment with a small amount of Valium can usually be done, if needed.
Injuries at home and on the playground are common. With the increasing popularity of after-school sports, the number of injuries seen has increased in recent years. A common ankle injury such as a sprain can lead to the formation of painful scar tissue if not treated properly and can result in reinjury caused by damage sustained to certain protective nerve endings. Early diagnosis and immobilization followed by remobilization and conditioning are important.
Diagnosis using x-ray and ultrasound
We have in our offices high resolution 12mHz ultrasound imaging which compares favorably with MRI for certain tendon and joint surface injuries, and can be done instantly and at a fraction of the cost. If swelling around a growth plate is seen on ultrasound, further work up can be done using CT or MRI as needed. Children ages 10-13 can sometimes develop inflammation on the back of the heel where the Achilles tendon attaches. There is a growth plate of sorts called a secondary center of ossification that can become inflamed and quite painful, causing the child to limp and complain of pain following activity. Usually it is somewhat improved by the next day and the cycle continues for 12 to 18 months on average. If this condition is suspected, the heel is imaged using X-ray and ultrasound. The bone may appear irregular and fragmented on X-ray and a high resolution ultrasound will show excessive inflammation around the edges of the ossification center.
Sometimes childhood arch pain is caused by malformation of the navicular bone on the inside of the arch. The bone undergoes a detour in its normal maturation and can be seen on X-ray as a thin line instead of a normal appearing bone. Because it is a growth related condition it is self-limiting and resolves in 12 to 18 months or slightly longer. Treatment is aimed at removing abnormal stresses from the developing bone and a molded shoe insert is essential to maintaining a level of activity.
Formation of extra bones
The navicular bone is the capstone of the arch. All of the forces of the arch converge on the navicular. The main tendon responsible for holding up the arch is attached to the navicular. Sometimes, as a normal genetic variation, the bone doesn't form properly or is associated with an extra or accessory bone. The insertion of the arch support tendon is altered such that a painful and permanent flatfoot condition develops. The larger the extra bone the more painful the condition. Treatment is aimed at propping up the arch with a shoe insert and then monitoring progress. An arch support will usually need to be worn in adulthood as well. In extreme cases the extra bone is removed surgically and the tendon is reattached.
Posted by Mark A. Kuzel, DPM, FACFAS on March 16, 2010