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PenttiKallio

Painful Conditions of the Ankle and Foot in Children and Adolescents

Köhler's disease

  • Extremely rare aseptic necrosis of the navicular bone at the age of 3 to 7 years
  • Symptoms include pain, swelling proximally in the foot and limping. Weight bearing worsens the symptoms.
  • Diagnosis is based on x-rays; the navicular bone appears underdeveloped and fragmented. The x-rays should be compared with those of the other foot.
  • Recovery is spontaneous. A cast can be applied for a short time to alleviate pain.

Sever's disease

  • Pain in the achilles tendon insertion in children (7-11 years). The pain is often bilateral.
  • The pain is worst after physical exercise.
  • On palpation the sides of the heel bone are painful but not swollen.
  • Radiology is not necessary if the symptoms and findings are typical.
  • X-rays may show sclerosis and irregularities of the calcaneal apophysis, but this can be seen also in asymptomatic individuals.
  • The pain disappears spontaneously in adolescence. In less severe cases, reducing load suffices. In mild cases the patient should avoid all jumping and running for 6 weeks.

Freiberg's disease

  • Aseptic necrosis of the head of a metatarsal bone (usually 2nd , sometimes 3rd or 4th ) in children and young adults
  • Symptoms include: pain and swelling at the metatarsal head; on palpation the head feels thickened. Limited motion of the MTP joint is evident.
  • X-rays show a flattened and fragmented metatarsal head.
  • Treatment: Shoes with thick soles, shoe inserts, or a transversal arch bar in the sole. A short cast treatment may be necessary, but surgical therapy is not usually warranted (removal of fragments, shaping of the head or removal) before conservative treatment has been tried for 1-2 years.

Supernumerary navicular bone (os tibiale externum)

  • A common accidental finding; a sesamoid bone in the posterior tibial tendon
  • May form a painful pseudarthrosis or may be attached to the navicular bone. The prominence may cause discomfort in association with flat feet, and cause compression in the shoe, particularly in skates and ski boots.
  • Symptoms commence at pre-adolescence, and usually subside with skeletal maturity. Symptoms rarely persist in adulthood.
  • Treatment includes temporary reduction of physical activity and well-fitting shoes or boots. In severe acute pain (recent partial tendon avulsion) below knee plaster cast for 4-6 weeks is indicated. Surgery is sometimes indicated.

Flat foot (pes planovalgus)

  • Pes planovalgus refers to the flattened longitudinal arch of the foot (planus) and to the outward tilting of the heel bone (valgus). In flexible (reducible) planovalgus foot, the longitudinal arch will regain its vaulted form and the heel position will be corrected when the patient hangs by the arms or rises on tiptoe, whereas a fixed, irreducible pes planovalgus remains unchanged.
  • In small children, planovalgus foot is so common that it is considered to belong to the normal age-related variation. The prevalence in 3-6-year-olds is 44%.
  • Flexible planovalgus in a small child will usually correct spontaneously as the muscular forces direct the growth. Insoles or special shoes will not affect the natural development. The finding is usually benign and no treatment is needed. As a matter of fact, the most important disadvantage of flat feet in children is medically unsubstantiated and expensive overtreatment and indoctrinating an unnecessary feeling of illness in healthy children.
  • A flexible planovalgus and other morphological variations in the childhood as well as actual severe deformities as such are basically painless.
  • A painful or rigid unilateral planovalgus is not physiological. It may be caused by arthritis, tarsal coalition, post-traumatic sequeala or a tumour.
  • There is no evidence of a causal association between foot morphology and other musculoskeletal problems such as growing pains in childhood or knee, hip or back problems in adulthood. The form of the feet does not affect the sporting ability of children or adolescents.
  • Instructions to stretch the gastrocnemius muscles and serial casting performed by a physiotherapist require good cooperation with the patient but when applied at the right age period they may be beneficial.
  • There is no evidence on the effectiveness of therapy with orthotic insoles Non-Surgical Interventions for Paediatric Pes Planus.
  • In some children, spontaneous correction will not take place. The background reason in such cases may be pathological muscle hypotony of various causes and/or an overtight gastrocnemius muscle.
  • The functional and aesthetic impairment caused by a severe planovalgus foot may require surgical treatment (lengthening of the gastrocnemius muscle + a correction aimed at a bone and a joint + casting for approximately 2 months) at the earliest after the age of 7-10 years.
  • Refer to a specialist (paediatric orthopaedist or rheumatologist)
    • patients with a rigid planovalgus foot and with pain in the movement of the subtalar joint regardless of the age
    • children over 7 years of age with such a severe aesthetic or functional impairment that the patient and the parents are prepared to surgical treatment.

    References

    • Pfeiffer M, Kotz R, Ledl T, Hauser G, Sluga M. Prevalence of flat foot in preschool-aged children. Pediatrics 2006 Aug;118(2):634-9. [PubMed]
    • Wenger DR, Mauldin D, Speck G, Morgan D, Lieber RL. Corrective shoes and inserts as treatment for flexible flatfoot in infants and children. J Bone Joint Surg Am 1989 Jul;71(6):800-10.[PubMed]
    • García-Rodríguez A, Martín-Jiménez F, Carnero-Varo M, Gómez-Gracia E, Gómez-Aracena J, Fernández-Crehuet J. Flexible flat feet in children: a real problem? Pediatrics 1999 Jun;103(6):e84. [PubMed]