General Discussion

Children can have pain in their feet and legs and never complain about it. Common areas of pain in the growing child are the balls of the feet, the heels and the knees. Aching in the legs (Restless legs) is also common and frequently called growing pains. What should be remembered is that growing does not normally hurt. Pain is a sign that something abnormal happening and should be regarded as a warning sign.

In the infant, pre walker and early walker signs that something abnormal is occurring include excessively bowed legs, curved feet, in-toeing or out-toeing, excessive tripping or stumbling or excessive toe walking. Any newly walking child who prefers to be carried or held instead of exploring their new world maybe communicating discomfort with standing or walking. Hip and back pain in children is not common and should be evaluated by your doctor early.

Freiberg's Disease

The spontaneous development of pain in children generally indicates some form of injury to the growth plate of a growing bone. This can occur without a specific memorable event. When pain occurs in the ball of a child's foot the most likely cause is injury to the growth plate of one of the long bones behind the toes called metatarsals. The most common bone involved is the metatarsal behind the second toe. When numbering the toes the big toe is the first toe.

This condition is called Freiberg's disease. This disorder is most frequently seen in the adolescent between the ages of 13 - 15 years of age. It is three times as likely to occur in females as compared to males. The pain is a result of a loss of blood flow to the growth plate in the bone.

Diagnosis

The diagnosis of Freiberg's disease is made by x-ray evaluation. X-rays will reveal a flattening of the head of the metatarsal bone. Early changes may be very subtle or not apparent. On physical exam there may be swelling in the area that is tender to touch. A useful tool for diagnosing growth plate injuries and stress fracture is to strike a tuning fork and placing the vibrating tuning fork on the area of the suspected site of injury. Pain with vibration may indicate bone or growth plate injury.

Treatment

Treatment consists of reducing pressure under the affected bone. This may consist of anything from using crutches to a custom insole for the shoe called an orthotic. Left untreated the affected bone may not develop properly and permeate damage to the joint behind the affect toe may result in painful arthritis. Once the joint becomes arthritic surgery to place an artificial joint may be required.

Osgood-Schlatter Disease

Knee pain in children may be caused by a variety of conditions. Some of these conditions may be rare but can be quite serious in nature. Knee pain in children should be evaluated by your doctor.

Osgood-Schlatter Disease

A common cause of knee pain in a growing child is injury to a growth plate in the front of the knee. This may be accompanied by swelling in the area. This condition is called Osgood-Schlatter Disease . It occurs most commonly in children between the ages of 10 -14. It is often associated with playing sports and aggressive bicycle riding. It is felt that the condition is primarily caused by an abnormal pull of the tendon that attaches into the painful area from the kneecap. This tendon is called the patellar tendon.

Treatment of Osgood-Schlatter Disease

Treatment consists of avoiding activities that aggravate the condition such as kneeling or excessive flexion of the knee. Icing the area and anti-inflammatory medications such as Tylenol or Advil may provide temporary relief. Often the abnormal knee function is due to the way the foot functions. In this instance the foot causes the lower leg to rotate slightly inward. This causes the patellar tendon to pull in an abnormal direction where it attaches in front of the knee causing damage to the growth plate in this area. If this is the cause of the problem then treatment might consist of a custom fitted shoe insert called an orthotic. The orthotic corrects the underlying foot condition that is affecting the lower leg and knee. A podiatrist trained in the use of functional orthotics should be able to evaluate the cause of the problem and if it is caused by abnormal foot function adequately treat the condition.

Pain in the Balls of a Child's Foot

Freiberg's Disease

The spontaneous development of pain in children generally indicates some form of injury to the growth plate of a growing bone. This can occur without a specific memorable event. When pain occurs in the ball of a child's foot the most likely cause is injury to the growth plate of one of the long bones behind the toes called metatarsals. The most common bone involved is the metatarsal behind the second toe. When numbering the toes the big toe is the first toe.

This condition is called Freiberg's disease. This disorder is most frequently seen in the adolescent between the ages of 13 - 15 years of age. It is three times as likely to occur in females as compared to males. The pain is a result of a loss of blood flow to the growth plate in the bone.

Diagnosis

The diagnosis of Freiberg's disease is made by x-ray evaluation. X-rays will reveal a flattening of the head of the metatarsal bone. Early changes may be very subtle or not apparent. On physical exam there may be swelling in the area that is tender to touch. A useful tool for diagnosing growth plate injuries and stress fracture is to strike a tuning fork and placing the vibrating tuning fork on the area of the suspected site of injury. Pain with vibration may indicate bone or growth plate injury.

Treatment

Treatment consists of reducing pressure under the affected bone. This may consist of anything from using crutches to a custom insole for the shoe called an orthotic. Left untreated the affected bone may not develop properly and permeate damage to the joint behind the affect toe may result in painful arthritis. Once the joint becomes arthritic surgery to place an artificial joint may be required.

Pain in the Heel of a Child's Foot

Sever's Disease

The spontaneous development of pain in children generally indicates some form of injury to the growth plate of a growing bone. This can occur without a specific memorable event. When pain occurs in the heel of a child the most likely cause is due to injury of the growth plate in the heel bone. This is called Sever's disease. A condition that may mimic Sever's disease is Achilles tendonitis. Achilles tendonitis is inflammation of the tendon attached to the back of the heel. A tight Achilles tendon may contribute to Seiver's disease by pulling excessively on the growth plate of the heel bone. This condition is most common between the ages of 8 - 15 years of age and boys tend to be affected more than girls. It is frequently seen in the active soccer, football or baseball player. Sport shoes with cleats seem to aggravate the condition. It is believed that the condition is due to an underlying mechanical problem with the way the foot functions.

Treatment

Home treatment consists of calf muscle stretching exercises, heel cushions in the shoes, and/or oral anti-inflammatory medications like Tylenol or Advil. Icing the area may provide some temporary relief. If the condition persists the child should be evaluated by a podiatrist for abnormal foot function. In severe cases a below the knee walking cast may be required. Treatment may require the use of custom-made shoe inserts called orthotics. Orthotics work by correcting foot function and will fit into most normal shoes.

Pain in the Knees of the Growing Child

Knee pain in children may be caused by a variety of conditions. Some of these conditions may be rare but can be quite serious in nature. Knee pain in children should be evaluated by your doctor.

Osgood-Schlatter's Disease

A common cause of knee pain in a growing child is injury to a growth plate in the front of the knee. This may be accompanied by swelling in the area. This condition is called Osgood-Schlatter's disease. It occurs most commonly in children between the ages of 10 -14. It is often associated with playing sports and aggressive bicycle riding. It is felt that the condition is primarily caused by an abnormal pull of the tendon that attaches into the painful area from the kneecap. This tendon is called the patellar tendon.

Treatment of Osgood-Schlatter's Disease

Treatment consists of avoiding activities that aggravate the condition such as kneeling or excessive flexion of the knee. Icing the area and anti-inflammatory medications such as Tylenol or Advil may provide temporary relief. Often the abnormal knee function is due to the way the foot functions. In this instance the foot causes the lower leg to rotate slightly inward. This causes the patellar tendon to pull in an abnormal direction where it attaches in front of the knee causing damage to the growth plate in this area. If this is the cause of the problem then treatment might consist of a custom fitted shoe insert called an orthotic. The orthotic corrects the underlying foot condition that is affecting the lower leg and knee. A podiatrist trained in the use of functional orthotics should be able to evaluate the cause of the problem and if it is caused by abnormal foot function adequately treat the condition.

Pediatric Flatfoot

A flatfoot deformity is where the arch on the inside border of the foot is more flat than normal. Flatfoot deformities can occur in all age groups, but appear most commonly in children. Some of these children grow up into adults who have feet with normal arches, but many of these children have pain related to their flatfoot deformity throughout their lives. It is very important that children with flatfoot deformity be evaluated by a podiatrist to determine if they need treatment to prevent future pain or deformity in their feet.

When the young child starts to first walk at about the age of 9-15 months of age, the foot has a fat or chubby appearance where there is a less bony architecture apparent in the foot. At this point in the development of the foot, it is very difficult to evaluate whether the child will have future problems with a flatfoot deformity.

At the ages of two and three, the child's foot starts to show more of its characteristic shape since the foot is less fat and the bones are more prominent. If the child has a flatfoot deformity at the ages of two to three, then it is wise to have the foot examined by a foot specialist such as a podiatrist. The reason that it is important to have the feet examined at this age is because the young foot is still largely made of cartilage, with less bone than would be present in the adult foot. Since cartilage is relatively soft, the abnormal forces caused by a flatfoot deformity may cause permanent structural alterations to the bones and joints of the foot that will persist into adulthood.

The flatfoot deformity in children causes a number of changes to the structure of the foot which is easily recognizable by the trained podiatrist. Flatfoot deformity causes the inside arch to be flattened, causes the heel bone to be turned outward, and causes the inside aspect of the foot to appear more bowed outward than normal. Most cases of flatfoot deformity in children are also associated with excessive flexibility in the joints of the foot which is commonly caused by ligamentous laxity.

Since the flatfoot deformity causes some instability of the foot during gait, children with flatfoot deformity may have complaints in the foot such as arch, heel, or ankle pain which is generally associated with increased standing, walking, or running activities. However, since the excessive rolling inward of the arches of the foot also make the leg and knee more turned inwards, children with flatfeet may also complain of pain in the low back, hip, knee, or leg due to the abnormal mechanics of the foot which is created by the flatfoot deformity.

Diagnosis

As mentioned above, the pediatric flatfoot deformity can be diagnosed at a very early age, but is unlikely to be properly diagnosed unless the doctor is a foot specialist, like a podiatrist, and is familiar with the intricacies of the structure and biomechanics of the foot. After speaking with the parent and child, the podiatrist will examine the foot both while the child is not bearing weight but also while the child is standing, walking or running. Often, the family history is also taken since the foot should be examined closely if the child has a close relative who had a painful flatfoot deformity as a child or adult.

During the examination of the child, the podiatrist is looking for abnormal structure or function of the foot and lower extremity, which could lead to either problems during childhood or adulthood. X-rays may be taken of the foot if a significant pathology is noted or suspected. The more severe the flatfoot deformity and the more significant the complaints in the foot or lower extremity, then the more likely the podiatrist will recommend specific treatment for the flatfoot deformity.

Treatment

If the child has a mild flatfoot deformity and no symptoms, then generally no treatment is recommended other than possibly yearly check-ups by the podiatrist. If, however, the child has a moderate to severe flatfoot deformity of has significant symptoms in the foot or lower extremity, then treatment is indicated.

Treatment generally starts with both supportive shoes, such as high tops, and some form of in-shoe insert such as arch padding for the milder cases of flatfoot deformity. More significant cases of flatfoot deformity may require more exacting control of the abnormal motion of the foot such as that offered by functional foot orthotics. Functional foot orthotics limit the abnormal flat arch shape and rolling in of the heel bone during standing, walking and running activities which helps not only improve the appearance and function of the foot, but also greatly reduces the symptoms in the foot or lower extremities. Calf muscle stretching exercises are also commonly prescribed for children with tight calf muscles since the tight calf muscles can worsen the flatfoot deformity with time and make the child's symptoms worse.

If the child has a severe flatfoot deformity and disabling symptoms which does not respond to foot orthotics, shoes and/or stretching, then surgery to correct the flatfoot deformity may be indicated.

These children may be candidates for a 15 minute outpatient procedure to correct the flexible flatfoot deformity which is referred to as hyperpronation. The procedure is called a Subtalar Arthroereisis. It involves the placement of an implant in the space under the ankle joint (sinus tarsi) to prevent only the abnormal motion, but still allowing normal motion. This brief procedure only requires very little recovery time, and is completely reversible, if necessary. Your surgeon can consult you about this exciting, life-changing procedure, or more information can be obtained at www.hyperpronation.com.

Restless Legs or Growing Pains

Weakness in the leg muscles, contracture with limitations in the movement in the joints of the legs or feet should be evaluated by your physician immediately.

When a child complains of soreness in the legs it is frequently said that they are having "growing pains". In fact the act of growing is not a painful condition. "Growing pains" indicate that something abnormal is occurring. The muscles in the lower leg control the function of the foot. When the feet are not functioning properly it causes the muscles in the legs to fatigue. This fatigue results in soreness or cramping in the muscles of the legs. This may manifest itself early in development of the child. A newly walking child may prefer to be carried or held instead of exploring their new world. Youngsters may protest walking in the mall or at amusement parks, tiring easily during a fun adventure.

Treatment

Treatment consists of using custom molded inserts for the shoes called orthotics to correct the underlying abnormal foot function. This in turn reduces the stress experienced in the leg muscles and will ease or eliminate the soreness. The results can be quite dramatic with a rapid improvement in the child's symptoms. As with all medical treatments results may vary and orthotics may failure to resolve the problem.

Sever's Disease

The spontaneous development of pain in children generally indicates some form of injury to the growth plate of a growing bone. This can occur without a specific memorable event. When pain occurs in the heel of a child the most likely cause is due to injury of the growth plate in the heel bone. This is called Sever's disease. A condition that may mimic Seiver's disease is Achilles tendonitis. Achilles tendonitis is inflammation of the tendon attached to the back of the heel. A tight Achilles tendon may contribute to Seiver's disease by pulling excessively on the growth plate of the heel bone. This condition is most common between the ages of 8 - 15 years of age and boys tend to be affected more than girls. It is frequently seen in the active soccer, football or baseball player. Sport shoes with cleats seem to aggravate the condition. It is believed that the condition is due to an underlying mechanical problem with the way the foot functions.

Treatment

Home treatment consists of calf muscle stretching exercises, heel cushions in the shoes, and/or oral anti-inflammatory medications like Tylenol or Advil. Icing the area may provide some temporary relief. If the condition persists the child should be evaluated by a podiatrist for abnormal foot function. In severe cases a below the knee walking cast may be required. Treatment may require the use of custom-made shoe inserts called orthotics. Orthotics work by correcting foot function and will fit into most normal shoes.