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Juho-AnttiAhola

Painful Conditions of the Ankle and Foot in Children and Adolescents

  • Painful conditions of the ankle and foot are common in growing children.
  • Most of these conditions are benign and self-limited.
  • Normal physical variation in the form of the foot (such as low or high plantar arch) is rarely associated with symptoms.

Overuse pain at ossification centre (apophysitis)

Sever's disease

  • Pain at the calcaneal ossification centre (apophysis), or Achilles tendon insertion, in children of 7-11 years
  • The pain is worst after physical exercise involving jumping or running.
  • There is pain on palpation mainly at the sides of the heel bone but no swelling.
  • The diagnosis is based on clinical findings, and x-raying is not necessary if symptoms and findings are typical.
  • Reducing strain that causes pain is sufficient treatment. A heel lift inserted in the shoe may be useful. Symptoms will subside with growth, usually before puberty.

Iselin's disease

  • Apophysitis of the proximal ossification centre of the fifth metatarsal bone
  • Typically occurs at a slightly younger age than Sever's disease.
  • Symptoms include typical pain and tenderness after exertion.
  • The treatment is symptomatic, as in Sever's disease.

Disturbances of the bone's blood supply (avascular necrosis, AVN)

Köhler's disease

  • Rare idiopathic disturbance of blood flow in the navicular bone (os naviculare) leading to necrosis (AVN).
  • Symptoms include pain, swelling in the proximal part of the foot and sometimes limping. Strain worsens the symptoms.
  • Diagnosis is based on x-rays; the navicular bone appears underdeveloped, sclerotic and fragmented.
  • Recovery is spontaneous. Short immobilization with an orthosis, for example, can be considered if the symptoms are difficult.
  • After Köhler's disease, the navicular bone will remain smaller than normal and it may be susceptible to stress fracture at a later age. Nevertheless, restricting physical exercise or strain is not necessary once the symptoms have subsided.

Freiberg's disease

  • Idiopathic disturbance of blood flow in the distal head of a metatarsal bone (usually 2nd, sometimes 3rd or 4th) leading to necrosis (AVN).
  • Symptoms include pain, swelling and limited movement of the MTP joint.
  • X-rays show a flattened, widened and fragmented metatarsal head.
  • The treatment is symptomatic.
    • Shoes with thick soles, insoles reducing strain on the painful area
    • In growing children, the symptoms almost invariably subside within 1-2 years, and invasive treatment is hardly ever indicated.

Accessory navicular bone (os tibiale externum)

  • A common incidental finding
  • A supernumerary, or sesamoid, bone in the posterior tibial tendon medially to the navicular bone.
  • The junction of the accessory bone and the navicular bone may become sore on exertion.
  • The accessory bone and the navicular bone typically cause a medial prominence on the foot that may cause friction particularly against stiff footwear (skates, ski boots).
  • Symptoms commence in early adolescence after the foot has stopped growing. Symptoms rarely persist in adulthood.
  • Treatment includes stress reduction and well-fitting footwear (modification of stiff footwear, such as skates and ski boots, in particular).
  • If severe symptoms persist, the condition can be treated surgically either by excising the accessory bone or by fusing it with the navicular bone. Conservative treatment should generally be continued for one year, at least, before resorting to invasive treatment. The condition has a high tendency to heal spontaneously.

Flat foot (pes planovalgus)

  • Pes planovalgus denotes a flattened longitudinal arch of the foot (planus) and tilting of the heel bone outward from the midline (valgus).
  • In growing children, planovalgus foot is usually considered to be a normal variation in the form of the foot.
    • There are no radiological or clinical limits defining the difference between ‘normal' and ‘flat' foot.
    • Defining an otherwise asymptomatic foot as an abnormal flat foot will cause unnecessary worry and feeling of illness in children and their families.
    • Special footwear, insoles or exercises guided by a physiotherapist have no effect on the structural development of the foot.
  • It is essential for treatment to differentiate between flexible and rigid flat foot.
    • In a flexible planovalgus foot, the longitudinal arch regains its vaulted form when the ankle is extended (when tiptoeing, for example).
    • In a rigid pes planovalgus, the sole remains flat regardless of ankle position, and tiptoeing may not be possible.
  • A flexible flat foot in a growing child should generally not be considered the cause of foot pain.
  • In patients with a rigid flat foot, there may be an underlying disease requiring treatment.
    • Arthritis
    • Tarsal coalition
    • Post-traumatic sequela
    • Neurological cause
  • In the treatment of physiological flat feet, it is most important to inform the patient and the family that this is normal. Unnecessary treatment, such as use of insoles, should be avoided.
  • A rigid flat foot or, rarely, a severe flexible flat foot may cause functional or aesthetic problems requiring surgical treatment.
    • The procedures required depend on the underlying cause.
  • Referral to a specialist (paediatric orthopaedist or paediatric rheumatologist)
    • Refer patients with a rigid planovalgus foot and with pain on movement of the subtalar joint regardless of age.
    • Refer children over 7 years of age with such severe aesthetic or functional impairment that the patient and the parents are prepared for surgical treatment.
    • When referring a patient for assessment of surgery, make sure that the patient and the family understand that recovery from such a procedure will take several months.

Talipes arcuatus

  • Like flat foot, talipes arcuatus, or high longitudinal arch of the foot possibly associated with inward tilting of the heel bone (varus), may represent a normal variation in the form of the foot.
  • If a high longitudinal arch is associated with turning in of the foot at the heel (cavovarus), the finding should generally be considered pathological.
  • In two out of three cases, cavovarus has a neurological cause.
    • Peripheral nervous causes (neuropathy, traumatic nerve damage)
    • Central nervous causes (CP)
    • Causes associated with the spinal cord (cleft spine, tumour, tethered cord)
    • Rare syndromes and skeletal diseases
  • Mild, asymptomatic and symmetrically high longitudinal arches do not require further investigations. Unilateral talipes arcuatus, cavovarus foot and progressive malposition always require further investigations in specialized health care.

Tarsal coalition

  • Tarsal coalition is an abnormal congenital connection between foot bones.
    • The connection may be bony, cartilaginous or fibrotic.
  • The pain associated with such coalition usually appears towards the end of foot growth, in girls after the age of 12, in boys slightly later.
  • Coalition between the heel bone and navicular bone is the most common.
    • Pain on pushing off, inversion-eversion of the foot on rotation
    • Usually located slightly anterior to the lateral malleolus.
    • May be visible in an oblique projection on foot x-ray.
  • Coalition between the ankle bone and heel bone is rare.
    • Stiffness of the lower ankle joint, and foot pain
    • The diagnosis usually requires tomography (MRI/CT).
  • Symptoms of only short duration can be followed up in primary health care. The primary treatment is reducing strain causing pain. In the case of coalition between the heel bone and navicular bone, in particular, the symptoms may subside with growth without any intervention.
  • If the symptoms persist, the patient should be referred to specialized care for further investigation and treatment planning.

    References

    • Evans AM, Rome K, Carroll M, et al. Foot orthoses for treating paediatric flat feet. Cochrane Database Syst Rev 2022;1(1):CD006311 [PubMed]
    • Sanpera I, Villafranca-Solano S, Muñoz-Lopez C, et al. How to manage pes cavus in children and adolescents? EFORT Open Rev 2021;6(6):510-517 [PubMed]
    • Mosca VS. Flexible flatfoot in children and adolescents. J Child Orthop 2010;4(2):107-21 [PubMed]
    • Pfeiffer M, Kotz R, Ledl T, et al. Prevalence of flat foot in preschool-aged children. Pediatrics 2006;118(2):634-9 [PubMed]