CHILD'S FOOT & ANKLE
HEALTH CARE

PEDIATRIC HEEL PAIN

It would not be much of a stretch to say that children are active, or at least, they should be. Sitting in front of a computer is not a very good way to develop the coordination and strength that are so important for optimal health. So when an active, sports-minded ten year old is unable to enjoy his favorite sports and activities because of pain, his parents will likely be notified. Such is the situation that many parents find themselves in, when their offspring suddenly begins complaining of foot pain.

But first, let’s talk about growth. How does this occur, the growth of an individual? This question may beget the question of why is growth painful for many children? This is a surprisingly difficult question, one which has elicited many theories, but few definitive answers.

Most bones add length through the action of growth plates, in which new bone is laid down at the ends of the shaft of a bone from a “plate” of fibrous tissue. This results in an increase in the length of the bone. The rate at which this production occurs varies depending on many factors, with the oft-described growth spurt being a visible increase in this rate.

But let’s get back to our ten year old, active, sports-loving subject who we will call Paul. What began as an occasional and fairly mild discomfort grew to be a consistent, significant problem in which any physical activity, even a moderate one, produced pain in the back of the foot. Playing sports was no longer a possibility, at least not for any duration, nor with any intensity, because pain was reliably the result. We are talking about one unhappy child, and consequently, some unhappy parents!

A trip to the 24 hour medical care facility was of no benefit. The nurse there ordered x-rays and did an exam, but no signs of trauma or fracture were seen, and no indication of any infectious process were noted. Their recommendation was to see a podiatrist, at which point I came into the picture. Indeed, the physical exam I performed was unremarkable, except for some pain when I squeezed the back of the child’s heel.

What is most distinctive about this patient’s condition is really the location of their pain, and the clinical picture. Pain developing in the heel, around the age of 8 to 10 years of age, subsiding with rest, is an easy diagnosis, if one is familiar with Sever’s disease. This is another type of growth plate injury, very similar to Osgood-Schlatter, in which activity puts undue stress on the structures attaching to the growth plate at the knee.

These are both ‘traction injuries’, a condition where physical pull is placed on the end of a bone. Because this part of the bone is connected to the main part of a long bone only by the growth plate, excessive pull on the end of the bone will therefore pull on this plate. As mentioned, the growth plate is composed of a tough fibrous tissue, but it is not as strong as bone.

The location of Sever’s disease is critical, since the Achilles tendon, the largest tendon in the body with the most forces running through it, attaches at the back of the heel bone. When my patient was running and jumping, ie playing sports, this large tendon was pulling on the back of heel, which in turn pulled on the growth plate. You might be able to envision how this might be an “irritating” situation. Pain was the result.

The pain of Sever’s disease is well localized unlike “growing pains”, which are attributed by some to be due to an increased rate of bone production. Other theories for the cause of the more generalized, vague discomfort called growing pains, experienced by so many children, include that of poor biomechanical function, in which various muscles of the lower extremity are over-worked due to poor foot and leg architecture.

This is clearly a factor in Severs disease. If the youngster’s feet and legs do not function properly (ie poor biomechanics), there will likely be increased traction (or pull) on the heel bone. This is why many sufferers find relief from some kind of arch support, with the prescription type, aka foot orthoses, providing the most reduction of pain. Many other conditions can lead to the development of this problem. The afflicted individual may have a tight Achilles tendon, or may simply be overweight (from spending too much time playing on the computer?!), and so put greater pull on the heel’s growth plate.

A common prescription offered to these individuals is to rest, with less participation in sports and other physical activities. My medical philosophy is to allow these kids to be active as possible by reducing these pulling forces. A combination of stretching exercises, the use of heel lifts, foot orthotics, foot-ankle braces, all work to control the pull of the end of the heel bone on the growth plate. When used in various combinations, the sufferer of Sever’s disease is usually able to increase their sports activities substantially.

There are a variety of other causes of heel pain in kids. Although some are quite rare, they should be investigated so they can be (hopefully) ruled out. A stress fracture is treated very differently, as is a bone tumor. If your child complains of pain, don’t assume it’s simply “growing pains”. Sometimes these are due to a type of falling arch, which can generally be treated quite successfully. Many treatments exist for the dreaded Sever’s disease, with the worst of them being an admonishment to “just rest”.

PEDIATRIC FLAT FOOT

When discussing children, especially those of a friend or family member, one of those oft usedclichés that seems to so quickly spring to mind, is that they will “grow out of it”. Be it a hair-trigger temper, a lackadaisical attitude, or a tendency to weight gain, all manner of concerns can be dismissed easily with this simple phrase. Fortunately, this is indeed often the case. The physical, mental and emotional changes that occur as part of the maturation process can be profound, and result in an individual hugely different from the earlier “version”.

This is often the approach of physicians when exposed to a parents concern for their child’sflattened foot structure. Certainly, this is often the situation, whereby the rounded contours of the infant and toddler mask the true configuration of the child’s lower extremity bone structure, and as they mature, losing “baby fat” along the way, growing more skeletally mature, an observer can see the true shape of the arch develop. But a controversy rages, concerning how the arch should develop. What is normal, versus what is an abnormal, pathologically low arch, aka the pediatric flatfoot.

Yet the question remains: how can we best arrive at an accurate prognosis for a youngster with a flattened foot type. Specialists in pedal mechanics can generally agree that there are serious consequences to a planar (ie flat) foot type in an adult, but at what point does this type of deformity develop? A great challenge for today’s health care practitioner is having the knowledge base, and understanding, of this type of pathology, to discern when treatment is appropriate and necessary for a child with a flat foot.

Further confusing the issue is that children often do not express pain as would an adult, and may only reveal some limitation in activities, without relating any actual pain. Thus, an essential question is whether a painless flat foot is an asymptomatic flat foot. There are a myriad of symptoms that may be experienced by a youngster with a severe flat foot, yet never using the “P” word. They may, for example, ask to be carried more than a peer of their age group. Another sign may be that they prefer sedentary activities, or, perhaps, have difficulty keeping up with their fellows. The signs may be subtle. Many experts believe that growing pains are primarily a problem in those with this foot type.

Those practitioners who have the opportunity to observe a child’s feet as the individual grows into adulthood are able to see the results. These include chronic heel pain, the development of hammer toes, even back pain, although these pathologies are much less common in pediatricpatients with flat feet. It’s a different situation though when a young person complains ofactual pain: the question of whether to treat is much easier.

The next big question is what type of treatment? Years ago, treatment was typically the prescribing of orthopedic shoes, which were certain to attract undesired attention in the school playground. Nowadays, first line therapy is often some type of arch support, but is an over-the-counter type of device sufficient? More exacting control of abnormal foot motion and position is possible with prescription foot orthotics. Functional foot orthotics limit the abnormal flattening of the arch, as well as the rolling in of the heel bone during standing, walking and running activities. This helps not only to improve the appearance and function of the foot, but also greatly reduces the symptoms in the foot or lower extremities.

For years, doctors have utilized various surgical options for more severe cases. Historically, this has consisted of the cutting of certain bones in the foot, then repositioning. When done correctly, these procedures can have profound effects on the sufferers quality of life, both in the present day, and into the future. But these are traumatic procedures, requiring prolonged recovery periods, with the potential for serious complications.

A very different approach has been developing for several decades, with great advances made recently in the design. With this method, a metallic implant is placed in the joint below the ankle (the sub-talar), which blocks abnormal motion of this joint. This particular joint is generally the “apex of the deformity”, and therefore the best location for placement of such a device. The benefits of this technique are many, and the correction of the deformity can be tremendous. Just as importantly, complications are few, and mild.

Whatever treatment is utilized, most specialists believe it is a mistake to assume a child will grow out of the condition. With or without symptoms, have your child evaluated by an appropriate physician. Although it may sound grandiose, an expert will agree, your offspring’s future happiness may depend on it. Schedule an appointment with our practice Superior Foot & Ankle Centers for a complete evalutation.

CLUBFOOT

Clubfoot is one of the most common non-life threatening major birth defects. It affects your child’s foot and ankle, twisting the heel and toes inward. It may look like the top of the foot is on the bottom. The clubfoot, calf and leg are smaller and shorter than normal. Clubfoot is not painful, is correctable, and your baby is probably otherwise normal.

Approximately one in every 1,000 newborns has clubfoot. Of those, one in three have both feet clubbed. The exact cause is unknown. Two out of three clubfoot babies are boys. Clubfoot is twice as likely if you, your spouse or your other children also have it. Less severe infant foot problems are common and are often misdiagnosed as clubfoot.

The goal of treating clubfoot is to make your newborn’s clubfoot (or feet) functional, painless and stable by the time he or she is ready to walk. Doctors start by gently stretching your child’s clubfoot toward the correct position. They put on a cast to hold it in place. One week later, they take off the cast and stretch your baby’s foot a little more, always working it toward the correct position. They apply a new cast, and one week later you come back and do it again.

This process (called serial casting) slowly moves the bones in the clubfoot into proper alignment. Doctors use X-rays to check the progress. Casting generally repeats for 6-12 weeks, and may take up to four months. About half the time, your child’s clubfoot straightens with casting. If it does, he or she will be fitted with special shoes or braces to keep the foot straight once corrected. These holding devices are usually needed until your child has been walking for up to a year or more.

Muscles often try to return to the clubfoot position. This is common when your child is 2-3 years old, but may continue up to age 7. Sometimes stretching, casting and bracing is not enough to correct your baby’s clubfoot. He or she may need surgery to adjust the tendons, ligaments and joints in the foot/ankle. Contact our practice Superior Foot & Ankle Centers for a complete evalutation.

SHORTER LEG TREATMENT

Most people obtain much of their medical knowledge from advertisements, gossip, and a host of unreliable sources. For example, it can be seen as amusing how often people don’t know that a problem can occur on only one side of the body. Most know that some internal organs are found on only one side, but many find it surprising that even the extremities can have differences. Sometimes these can be minor and of little clinical significance, while others can lead to a lifetime of pain and problems.

Low back pain is an incredibly common malady in our culture, due to a whole host of reasons. Once again, I am obligated to use the “E” word: epidemic. Back pain IS that common. About 80 percent of adults experience low back pain at some point in their lifetimes. It is the most common cause of job-related disability and a leading contributor to missed work days. In a large survey, more than a quarter of adults reported experiencing low back pain during the past 3 months. How many activities can be performed that don’t involve the back. For example, how about breathing?

Our bodies were not made to spend long hours sitting, nor are they well-suited to walking on hard, flat surfaces the great majority of the time. Variations in the alignment of the legs and pelvis can lead to chronic back pain, which is logical to most. An unexpectedly frequent explanation for chronic low back pain is a difference in length from one leg to the other. Yet this is so rarely measured, it might almost be seen as a plot. Many individuals go their entire lives, suffering to various degrees, from this terrible affliction, without being thoroughly evaluated for a leg length inequality.

Leg length differences are actually the rule, rather than the exception. Some estimates put the incidence of a leg length difference at 95%. Usually the differences are small, or the body is able to compensate in some fashion. Sometimes no symptoms develop. But frequently the body will develop compensatory mechanisms, which themselves can cause problems, or it is unable to fully make up for the difference. In either case, symptoms eventually occur with time. Pain will typically be experienced first on the longer leg, and can include a variety of problems. Some common examples are buttock pain, arthritis of the knee or hip, inflammation of a gluteal muscle, tendonitis at the knee cap, patellofemoral pain syndrome, heel pain (plantar fasciitis), shin splints or chronic pain at the ball of the foot (metatarsalgia).

Men and women are equally affected by low back pain, which can range in intensity from a dull, constant ache to a sudden, sharp sensation that leaves the person incapacitated. Pain can begin abruptly as a result of an accident or by lifting something heavy, or it can develop over time due to age-related changes of the spine. Sedentary lifestyles can also set the stage for low back pain, especially when a weekday routine of getting too little exercise is punctuated by a strenuous weekend workout.

Unfortunately, back pain is frequently caused by a structural condition, one which will not resolve over time. Leg length discrepancies are in this category. This abnormality can be caused by poor alignment of the pelvis or simply because one leg is structurally longer than the other. Some children are born with legs that are of unequal length, or there may be bowing of a shin bone. A length difference may result from how the body is functioning due to some abnormality present at birth. These may alter the alignment of the hips, and change how the structures that make up the leg and pelvis are working together. As you may have gathered, the anatomy is complex, further complicated by how everything is working together.
A variety of conditions can result in low back pain, including such disparate problems as a degenerated or ruptured disc, or a compressed nerve (a radiculopathy). A common condition, termed sciatica, is a nerve compression problem of the sciatic nerve. This pinching causes a shock-like sensation or burning through the buttocks and down one leg, occasionally reaching the foot. In the most extreme cases, when the nerve is pinched between the disc and the adjacent bone, the symptoms may involve not only pain, but numbness and muscle weakness in the leg because of interrupted nerve signaling.

Regardless of the reason, your body wants to be symmetrical and will do its best to compensate for the length difference. One of the most common ways to do that is by shortening the longer leg, and lengthening the shorter. How does it do that? The body has its own “elevator” system, which allows it to jack up the shorter side and lower the longer: it is the arch of the foot. A frequent finding on an x-ray of the feet, when they are taken with the person weight bearing, is where one arch is lowered and the other raised. This is an obvious clue to the presence of a leg length difference. The individual so afflicted will have no idea why they have this difference, and generally will not even be aware of the asymmetry.
When present for a sufficient length of time, the compensation may develop its own set of problems, even though that is not the true root of the problem. As might be expected, this may cause problems in the foot. Arch or heel pain may result, or stress to particular tendons or joints, and subsequently symptoms from these structures occur. It is not enough to treat the foot pain; recognizing and evaluating limb length discrepancy is necessary for long term relief.

Chronic low back is often treated with anti-inflammatory medication, which does tend to help. If the cause is a transient strain of some of the musculature in the region, this approach may be sufficient. In some, there can be a structural pathology, such as the previously-discussed leg length difference, and so the benefits will not be lasting. Physical therapy is commonly utilized, and is often beneficial. Appropriate exercises and stretches can help to relieve much of the pain that has developed, yet the benefits will again be transient if the structural difference is not compensated for.

Frequently, a steroid injection is used to treat the inflammation that has developed from the chronic stress to some of the joints of the back or the pelvis. Steroids are powerful anti-inflammatories, and so can produce significant relief of symptoms. Yet again, without addressing the underlying cause of the problem, the benefits are not lasting. One solution is to surgically lengthen the shorter leg. The science of orthopedics has progressed to the point where we can do this. But this is a very specialized type of surgical procedure, and not commonly performed.

The solution is incredibly simple: a heel lift, which eradicates the need for compensation by the body. How much should be added under the heel is certainly a good question, but that’s where a thorough exam comes into play. Recognizing the cause, with a thorough evaluation, will allow a physician trained in musculoskeletal medicine to determine how much, and how quickly, to accommodate the shorter limb. If you suffer from chronic low back pain, with pain that continues to recur, you may have a limb length discrepancy. Remember, the solution is simple. So, schedule an appointment with our practice Superior Foot & Ankle Centers and have it checked out; you need your back….to do most anything!