Happy Feet


   We take our children to the pediatrician for annual check-ups.  Each new tooth is celebrated, and the first trip to the dentist is a milestone.  The trip to the shoe store is an event, too, but what about the health of their precious podiatric parts? (‘Feet’ in lay terms!)

   Proper diagnosis and treatment of podiatric conditions in children is vital because these injuries are often more symptomatic later in adolescence — and even into our 30s and 40s. Doctors see certain conditions, not just in the budding young athlete but also in newborns and pre-walking infants. Common infant foot malformations such as metatarsus adductus (in-toeing) or calcaneal valgus (collapsing heel) can seem rather benign — but can be the source of numerous problems later on. 

   So, where does proper foot care for infants begin?

   With the first visits to the pediatrician, newborns go through a regimented physical to assess the hips, eyes, hearing, and other vital functions.  The physician will also look for pedal (pediatric foot) anomalies like those those mentioned, as well as clubfoot (u-shaped toe) and polydactylly (too many toes). Once a pediatrician has made an initial assessment, a trip to the podiatrist is often warranted.

   The podiatrist will perform a complete examination, often including X-rays. For the most typical infant podiatric problems, there are standard recommended treatment options, usually consisting of some type of casting and/or surgical procedures.

Metatarsus adductus and Primus met adductus (both forms of in-toeing) as well as calcaneal valgus are often noted by the parents who seem to “know something is wrong.”  Unless a professional properly evaluates the conditions, they are often ignored until the patient experiences more serious symptoms such as pathological flat foot, Achilles tendinopathies, and poorly shaped feet.  Only in the rarest case would surgery be warranted for these.  Usually, casting, night splints, shoe modifications and serial exams can easily minimize many of the long-term effects.

Clubfoot (U-shaped foot):  The gold standard for treatment is the Turco procedure.  This surgical procedure releases all the ligaments and allows the physician to set the foot in a more anatomically correct way.  Casting always precedes this procedure; serial casting gets the foot into as much of a corrected position pre-surgically as possible, maximizing the ultimate outcome. The clubfoot patient will often remain with a limb length discrepancy, unequal shoe size, tight Achilles, and a poorly developed lower leg.  These conditions are more often due to the original malformation in uteri and can be minimized with the proper surgical treatment, shoe gear and physical therapy. 

Polydactylly (too many toes) may need to be addressed depending on many factors.   Aesthetically, the child may be subject to taunts and teasing; practically, the child may have pain and not be able to be fitted with proper shoe gear.  In those cases, surgery is recommended and is usually performed at 10 to 12 years old, when growth plates are better defined.

Sprains and strains
   The adolescent years bring on other conditions.  These are often exacerbated by kids ignoring symptoms and not letting their parents know there is a problem until a condition gets critical.  The most often ignored and mistreated diagnosis is the sprain/strain caused by physical activity and trauma.  Sprain is commonly described as the “pull” of a ligament, while a strain refers to the overworking of a muscle.

   Ligaments in the adolescent and teenager are often stronger than bone (the opposite becomes true as we age). In certain cases, when a ligament is damaged, it can actually pull from the growth plate (avulsion) — causing a much more serious trauma to areas such as the ankle, and foot and big toe.  This is why suspected sprains must be thoroughly diagnosed and treated aggressively.

   Here is what to look for in adolescent feet:

Ankle sprains and strains in adolescents must be thoroughly evaluated and aggressively treated, because, as stated above, these injuries can actually be more serious and a misdiagnosis can lead to long-term instability. Both of these injuries may be missed by X-ray in the ER since they aren’t easily distinguished from normal structure. With radiological advances and more enhanced evaluation by a specialist, trauma to these areas can be thoroughly diagnosed and proper treatment rendered.

   If left untreated, the misalignment of the bone and cartilage may cause long-term repercussions, which will affect stressful physical activity, as well as activities of daily life.  How many adults do we know with weak ankles who cannot attribute it to any one occurrence? 

—Salter Harris Fractures (fractures to the growth plates) are another prime example of weak ankles in adulthood. Permanent damage to these areas is often not appreciated until much later in life. Salter Harris fractures are often not seen immediately, since on X-ray, growth plates often appear as fractures and fractures as growth plates. Severe injuries to these areas require casting and sometimes, surgery. Even minor injuries to these areas may cause uneven growth to the bone, causing improper alignment to the joints and arthritis later in life.  However, the most common injury, which goes misdiagnosed, is that of the “great toe”. 

The Hallux or big toe bears up to 10 times the weight of our body during heavy exercise.  Damage to the growth plates and cartilage most often manifests itself in our 30s and 40s.  Simple activities or light exercise become painful because the joint has become arthritic. Since children tend to bounce back from these injuries, proper treatment is often never rendered. 

   In many cases, this later arthritis could have been prevented or minimized with proper casting, immobilizing and shoe gear at the time of injury.  Appropriate treatment would have protected the joint and all the surrounding structures, allowing for normal growth and development of the area. 

   Watching for changes in foot appearance, listening to children describe painful or uncomfortable symptoms and visiting a podiatrist when warranted, are all good steps to ensuring healthy feet for a lifetime.

   After all, as Abraham Lincoln once said, “Be sure you put your feet in the right place, then stand firm.”  For those times that your children’s feet are in need, a podiatrist’s office may just be the right place.

JOHN VISCOVICH, D.P.M. is a Board-qualified rearfoot and forefoot reconstructive surgeon and is certified in arthroscopic ankle/foot surgery. He is in private practice in Mt. Kisco, where he treats adults, adolescents and children and specializes in diseases of the foot and ankle, foot sports injuries, orthotics, and foot surgery. He can be reached at (914) 244-0244 or via his website: www.nyfeet.com.