COMMON PEDIATRIC FOOT PROBLEMS
By: Corinne Gehegan, DPM
#1 Pediatric Plantar Warts – Plantar warts are semi-soft lesions that develop after exposure to a strain of HPV that may enter through tiny openings in the skin. Children are prone to exposure as the virus lives on surfaces that children’s feet often encounter such as the area around swimming pools as well as mats used for martial arts, dance, and gymnastics. Water parks and hotel bathrooms may also harbor the virus. Of course, children do not have to give up all of these fun activities; but it is wise to prevent direct contact of the foot with surfaces used by the general public. For further information regarding treatment options please read the article entitled Plantar Warts.
#2 Ingrown Toenails Parents often ask “Why did my child develop an ingrown toenail”? An ingrown toenail is simply a nail that has grown in such a way that pressure is applied to the skin next to the nail border. This leads to tenderness and inflammation. If the nail succeeds in piercing the skin an infection or small abscess (pocket of pus) may develop as now the skin is open to allow bacteria to enter. There may be a hereditary factor, but often the nature of the problem is mechanical. A child’s foot could be wider than the average width of a shoe. The child may have grown out of the shoe. The particular style of a shoe may be to blame. Participation in certain activities or sports may encourage this problem due to repetitive maneuvers. The condition could simply develop from a direct trauma to the toe or from improper nail trimming. For further information regarding treatment options please read the article Ingrown/Infected Nails.
#3 Fungus Among Us It is possible for a pediatric patient to develop the unfortunate fungal nail. This most frequently occurs if the nail was traumatized even slightly. If a portion of the nail is detached from the underlying skin (nail bed) fungus has the opportunity to find a home between the nail and the nail bed. Fungus prefers warmth, darkness, and moisture. This describes perfectly the environment underneath a nail (and inside of a shoe!). Nail fungus may also develop if a patient has a fungal infection of the skin commonly referred to as “athlete’s foot” (tinea pedis). If the skin is not treated the fungus may eventually find its way underneath the nails. For further information please read Fungal Nails and Athlete’s Foot.
#4 Heel Pain – Heel pain is a common pediatric complaint. Any child can develop heel pain, but is more commonly seen in patients who participate intensely in athletic activities, patients who are overweight, and in those who have certain biomechanical conditions such as a tight Achilles/gastroc complex (calf) or flat feet. Most often it can be classified as Sever’s Apophysitis. This is an inflammation of the growth plate (physis) of the heel bone (calcaneus). The bones of children’s feet are not fully developed until the age of 14-15 on average. Repetitive stress at the heel from surrounding soft tissue structures such as the Achilles tendon can lead to this inflammatory process. By saying “inflammatory” it does not mean that the heel will appear red, hot, or even swollen in the case of Sever’s. The only symptom may be pain. The pain is induced or may worsen with activities such as walking, running, and jumping. The pain is often located at the back and bottom aspect of the heel. One or both heels may be affected. Diagnosis is based on the history of the complaint, the clinical exam, and an X-ray to rule out a more rare condition such as a bone tumor or bone cyst. The parent should bring an example of the child’s casual and athletic foot wear. A treatment plan will be based on all of the above factors.
#5 Abnormal Gait Patterns Many children present with parents who are concerned about the way their child walks. In-toeing, out-toeing, and toe walking are some of the gait patterns that fall outside of the typical pediatric gait. In-toeing (pigeon toed) and out-toeing could stem from bone structure or from soft tissue imbalances. Curved foot or C-Shaped feet (Metatarsus Adductus), twisted shin bones (tibial torsion) or twisted thigh bones (femoral torsion) are structural causes. All three almost always self correct. Severe cases of metatarsus adductus can be managed with casts during infancy. Rarely do any of these conditions require surgery which is reserved for severe cases that impair function or result in discomfort. The range of motion at the hip may be determined to be excessive internally or excessive externally. This imbalance can lead to inward pointing feet or outward pointing feet. The imbalance can be corrected by avoiding certain positions while the child is seated and encouraging others. Stretching and other exercises are beneficial as well. Additionally, physical therapy may be prescribed. Toe walking may be habitual and in this case the child eventually “grows out” of this phase with the help of simple stretching exercises. Some patients are born with a congenitally short Achilles tendon which may be managed nonsurgically or surgically depending on the severity. Toe walking may also be associated with certain developmental delays and neurological/neuromuscular conditions. An ankle foot orthotic (AFO) may be beneficial for a temporary period of time. For additional information, please read Toe Walking and AFOs.
#6 Pediatric Flat Feet (Pes Planus, Pes Plano Valgus) Pes planus is a relatively common foot type, but it can be a complex condition with varying degrees of severity and a range of symptoms. It is often an inherited foot type. Most cases of pes planus are flexible meaning that the arch can be recreated by manually manipulating the foot or by having the patient stand on their toes. A rigid flat foot is more difficult to manage, but it is also rare. Controversy exists about how to manage flat feet and if they should be treated at all. Arch supports or orthoses will align the foot and ankle while providing support and stability, however, it is important to stretch certain muscle-tendon complexes and strengthen others so that the pediatric patient has as well conditioned feet as possible. Arch supports are analogous to eye glasses. The purpose is not to cure the problem. Severe or symptomatic cases of pes planus that do not respond well to orthoses may require surgical modalities. Surgical management may involve an implant that blocks excess arch collapse and over-pronation and/or soft tissue and bone reconstruction. The decision is preceded by history, clinical exam, patient’s goals, X-Rays, and often MRI. For further information please read Flat Feet.
Article written by Dr. Corinne Gehegan, Pediatric Foot Doctor
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