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Disorders of the foot and ankle are a common cause for orthopedic referral in
the infant, pediatric and adolescent patient.
The spectrum of problems is wide and while most, fortunately, are not
serious, some of the congenital abnormalities do require significant operative
intervention and a prolonged period of treatment. Even many of the less serious
problems are a source of major irritation to patients. They often put
limitations on the routine activities required by daily living. The following
are common foot and ankle disorders.
Congenital disorders
Metatarsus adductus: Metatarsus adductus is a common congenital foot abnormality and is caused by
a persistence of fetal positioning. It is one of the several congenital
abnormalities known as a "packaging problem".
"Metatarsus adductus" is a frightening sounding term but means
simply that the metatarsals (the long bones in the mid portion of the foot) are
adducted or angled toward the midline. The English have another name for this
condition -- they call it: "hooked forefoot." As with any medical
condition metatarsus adductus can run the gamut from mild to severe. While one
classification defines the degree of metatarsus adductus based on the amount of
curvature, a better classification relies on flexibility. Feet, which are very
supple typically require no treatment. Those feet that are least supple require
manipulation and stretching and the use of reverse last shoes or perhaps a short
period of corrective casting. Without treatment, most feet do spontaneously
improve by age 3. After age 4 surgery may be considered to correct the residual
deformity.
Clubfoot: Clubfoot is a more serious disorder that is not related to the intrauterine
environment, but to a growth abnormality that can be strongly influenced by
genetic predisposition. The clubfoot is hooked like the adducted foot, but has
true structural abnormalities that cause it to roll inward and point downward.
Untreated, this results in a major disability. Treatment begins with casting
and in about 40% of cases, minor surgical intervention is necessary for complete
correction.
Congenital vertical talus: Congenital vertical talus is a fairly rare, but serious condition. The
position of the foot is a classic "rocker bottom". It must be
differentiated from a hyper flexible foot, and if stiff, casting is minimally
useful and surgery is required.
Developmental disorders
Flatfoot: Flatfeet are very common and typically genetic in nature. It is due to lax
ligaments and/or tendons in the foot. The most common childhood flat foot is
supple, not stiff, and usually not painful. An additional underlying cause for a
stiff flatfoot must be sought. Shoe wear has not been shown to promote arch
development. An arch is usually present on standing by age 5. Arch supports (orthotics)
are indicated for painful, supple feet and for patients with additional symptoms
related to the feet (certain gait, knee and back disorders). Arch supports are
also indicated for those who wear out shoes extremely fast. Surgery can tighten
the ligaments or tendons but is reserved for the most severe flat feet.
In-toeing: In toeing ("pigeon toed") is typically not related to the feet but
to lower extremity rotation. Tibial (shin bone) torsion (twist) is the most
common cause of in toeing in the child age 1 2. Femoral (thigh bone) torsion
is the usual culprit in ages 3-15. Bracing is controversial for tibial torsion
and fully ineffective for the femur. Surgery is performed only on asymmetric
limbs or those with debilitating torsional abnormalities
Knock-knees: Knock knees are typical in children age 3 to 7. Knock knees come after
bowlegs and usually improve by age 11. Bracing is rarely required as resolution
is typically dramatic. The need for surgical intervention is rare.
Bowlegs: Bowlegs are typical in infants to age 1214 months and may be normal to
age 2. Most bowlegs are symmetric, stable and spontaneously resolve. Bracing has
shown benefit to age 34. Surgery is most often indicated for those with an
abnormality of the growth plate, a condition known as Blount's disease.
Overuse injuries
Achilles tendonitis:
Achilles tendonitis is an overuse injury seen rarely in children under age
14 but seen with greater frequency as skeletal maturity approaches. It is
characterized by pain with activity, particularly jumping sports in the region
of the Achilles tendon. Rest, activity modification, a stretching program, shoe
change, icing and the use of an anti inflammatory medication will usually
promote healing and the ability to return to sports. The Achilles tendon should
never be injected with cortisone as rupture due to weakening can occur.
Sever's disease:
Sever's disease is a pre-skeletal maturity condition resulting from
inflammation of the calcaneal (heel bone) growth plate near to where the
Achilles tendon attaches. The treatment is similar to Achilles' tendonitis with
the addition of a heel pad or heel cup. Occasionally this condition will plague
a youngster off and on for 2 3 years until growth plate closure occurs.
Casting to completely immobilize the ankle joint may be required.
Plantar fasciitis:
Plantar fasciitis is an inflammation of the plantar (sole of foot) fascia (a
tough band of ligament type tissue which runs along the bottom of the foot).
Again, treatment is directed at relieving inflammation and gently stretching the
involved tissues. Arch supports also help here to support the foot and decrease
pain. While injection is occasionally indicated in the adult, it is typically
not done in the younger population.
Stress fractures:
Stress fractures are fractures sustained as a result of repeated "micro
trauma". Sudden changes in training intensity are the classic cause of
these injuries that typically involve the metatarsals (the bones in the mid part
of the foot). Cessation of the activity that is causing the problem and casting
are the mainstays of treatment. If the activity continues prior to healing,
these micro fractures can become "real fractures".
Traumatic injuries
Ankle fractures:
Ankle fractures in the skeletally immature usually involve the growth plates
of the tibia or fibula (the two shin bones). They usually occur as a result of a
twisting injury to the ankle. An adult with the same type of injury would have
an ankle sprain (a tear in a ligament). Most of the ankle fractures seen in the
pediatric population do not require operative management but do if the fracture
line extends into the joint. Injury to the growth plate may, on occasion, result
in a growth disturbance.
Ankle sprains:
Ankle sprains in children are rare because the ligaments are stronger than
the growth plate, and the growth plate fails first under the "load" of
injury. When they do occur, some form of immobilization (cast or brace) is
indicated in order for the ligaments to heal at their normal length. Ligaments
that heal in a "lengthened" position result in long-term disability
and the increased likelihood of repeated ankle sprains under even minimally
vigorous loads.
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