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Paediatric Foot Disorders

Club Foot

Club foot is a common foot deformity present at birth where in one or both the feet are turned towards an inward and downward position. It is more common in boys than girls. It is also called as talipes equinovarus.

Club foot is of two types:

  • Postural or positional club foot – This occurs because of abnormal positioning of the foetus in the mother’s womb. The foot is flexible and can be moved to a near normal position after birth.
  • Rigid or fixed club foot – In rigid form, the foot is rigid or stiff as the muscles at the back of the lower leg become very tight.

Although club foot does not cause any pain, it can affect the physical appearance and the child’s ability to walk. Children with club foot may have abnormal foot where,

  • Foot may be slightly smaller than the normal
  • The front of the foot may be twisted toward the other foot
  • Stiff muscles in the lower leg which may affect range of motion

The exact cause of clubfoot is unknown. Genetic and environmental factors may have a role in developing the condition. Other congenital malformations such as spina bifida may also cause club foot.

Treatment options include:

Stretching and Casting - It is also known as the Ponseti method. The foot is manipulated into a correct position and a cast is placed to maintain that position. Repositioning and recasting is repeated for every 1 to 2 weeks for 2 to 4 months, each time bringing the foot toward the normal position. After realignment of the foot, it is maintained through splinting with braces to keep the foot in the corrected position. The brace is worn for 3 months following which it is worn only at night for up to 3 years, to maintain the correction.

Club foot repair – It is surgical repair of the birth defect which involves lengthening or shortening the tendons (tissues that help attaches muscles to bones) of the foot.

Osteotomy – It is a surgical procedure where a part of the bone is cut to shorten or lengthen its alignment. The procedure involves removal of a wedge-shaped bone located near the damaged joint and the remaining bones are joined together and secured using the staples or pins.

Fusion or arthrodesis – It is a surgical procedure where two or more bones are joined or fused together. Bone for fusion will be taken from other parts in the body. Metal pins or plates may be used to hold the bones in position.

Hallux Valgus

A hallux valgus or bunion is a bump on the base of the big toe due to enlargement of bone or soft tissues around the joint. Bunions develop due to imbalanced weight-bearing on the joints and tendons of your foot. This uneven shifting in pressure makes the joint unstable, slowly leading to the formation of a hard knob that protrudes out of your foot. The most common cause of a hallux valgus is prolonged wearing of ill-fitting footwear that are high-heeled, narrow, too small or pointy, with a narrow toe box, which compress the toes into unnatural positions.

Bunions are much more prevalent in women, causing pain with ambulation when wearing shoes, swelling, redness, decreased mobility of the toe and inward turning of the big toe toward the second toe. A hallux valgus can further lead to calloused skin at the base of the big toe and formation of corns and calluses.

When you present to the clinic with these symptoms, your doctor performs a thorough physical examination and may order X-rays to determine the extent of damage and deformity of the toe joints.

Treatment may include conservative treatment such as wearing properly fitted shoes with specially designed shoe inserts, padding and taping, physical therapy and certain medications. If conservative measures fail to treat the bunion pain, then your surgeon may recommend a surgical procedure to remove the bunion. There are several surgical options to treat a bunion. Soft tissues around the toe may be shortened or lengthened, swollen tissue removed, parts of the bone cut (osteotomy), and bones of the toe joint permanently fused with the placement of screws and plates to straighten the big toe.

Your surgeon will select the appropriate surgical procedure based on your presentation.

Sever’s Disease

Sever’s disease is a painful inflammation of the growth plate in the heel. Growth plates are areas at the end of children’s bones that undergo changes so bone growth can occur. During this time, the muscles and tendons may not grow as fast as the bone causing tightness and pressure at the back of the heel.   

With proper treatment, Sever’s disease usually resolves within 2 months with no long-term effects on the child.

Sever’s disease, also called calcaneal apophysitis, is a condition causing swelling and pain at the back of the heel that affects growing adolescents.

The inflammation occurs at the point where the Achilles tendon attaches to the calcaneus bone, the large bone that makes up the heel of the foot.

Severs disease is a common cause of heel pain in physically active children in the early part of puberty, usually between ages 9-14.

Symptoms

Symptoms of Severs Disease can include the following:

  • Pain in one or both heels, usually at the back
  • Difficulty walking, walking with a limp, or walking on tiptoes
  • Heel may appear red, swollen and warm
  • Pain when heel is squeezed on both sides
  • Usually seen in physically active children between 9 and 14
  • Symptoms improve with rest and worsen with activity

Causes

Severs Disease can be caused by the following:

  • Repetitive stress resulting from sports that involve running and jumping.
  • Standing for extended periods of time causing constant pressure on the heel
  • Poor fitting shoes and improper footwear

Risk Factors

Risk factors for developing Severs Disease include the following:

  • Physically active children at the onset of puberty who are involved in running and jumping activities are at increased risk of developing Sever’s disease.
  • Short leg syndrome, a condition where one leg is shorter than the other, can cause pulling of the Achilles tendon leading to Severs.
  • Being overweight creates more pressure on the growth plate.
  • Flat arches, high arches, or pronated foot, where the foot rolls inward, can cause tightness of the Achilles tendon thereby increasing pressure on the heel.

Diagnosis

Your physician will diagnose Sever’s disease based on medical history and physical examination. Your doctor performs a physical examination of the heel to assess for swelling, redness, and localized tenderness.  Your doctor may perform a squeeze test

 to assess whether pain occurs when squeezing the back part of the heel from both sides.

Although Severs Disease cannot be seen on X-ray, your physician may order them to rule out other problems such as a fracture.

Conservative Treatments

The goal of treatment is to relieve the pain. Treatment options include:

  • Rest
  • Ice
  • Compression
  • Exercises
  • Medications
  • Orthotic devices

Rest

 Any activities that cause heel pain should be stopped until the pain resolves.  Adequate rest relieves pressure on the heel bone reducing swelling and tenderness.

Ice or Cold packs

Ice wrapped in a towel should be applied to the injured heel for 20 minutes 3 times a day to reduce swelling.

Compression

Elastic wrap or compression stockings may be used to help reduce the swelling and pain.  Elevating the heel above heart level also helps with the swelling.

Exercises

 Calf stretch, heel cord stretch and hamstring stretch are performed to stretch and strengthen the leg muscles and tendons on the back of the leg. These should be done 2 -3 times a day, holding each stretch for 20 seconds.

Strengthening exercise using a bungee cord or rubber tubing are also performed 2-3 times a day to strengthen the muscles on the front of the shin. The child should sit on the floor keeping the affected leg straight. One end of the bungee cord is tied around a table leg and the other end around the child’s toes. Then the child moves back just far enough to stretch the cord. The foot is slowly bent towards the child’s body, then the foot is pointed towards the table in the opposite direction.

Medications

Over the counter NSAID’s may be taken to reduce the pain and swelling. Never give children aspirin due to risk of a serious illness called Reyes Syndrome.

Orthotic devices

 Orthotic devices such as heel pads, heel lifts or heel cups are recommended in children with pronated feet, and flat or high arches. These provide cushion to the heel and reduce the strain on the Achilles tendon.

In severe cases, a short leg cast may be applied for 4 to 6 weeks to immobilize the foot so that it can heel.

Prevention

Sever’s disease can be prevented with the following recommendations:

  • Wearing good quality, well-fitting shoes with a shock-absorbent sole to reduce pressure on the heel
  • Avoid heavy or high heeled shoes
  • Avoid excessive running on hard surfaces
  • Stretching exercises and ice application should be continued after sports activities to prevent recurrence of Sever’s disease.

  • British Orthopaedic Foot & Ankle Society
  • Royal College Of Surgeon
  • BMI Healthcare
  • London Musculoskeletal Centre
  • Hillingdon Hospital
  • Princess Grace Hospital
  • HCA Healthcare UK