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Foot Pain in Children
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Common Orthopedic Problems
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Foot Pain in Children Richard H. Gross, M.D. *
Foot pain in children is not an unusual complaint. The evaluation of such a complaint, however, is often confounded by the fact that most pediatricians have had little exposure to this type of problem during their training. In addition, there are divergent opinions by recognized authorities on the symptomatology and management of such common problems as the pronated foot. The purpose of this paper is to outline an approach to the child with foot pain and to offer suggestions for the management of the more common problems.
CLINICAL EVALUATION The evaluation of a child with foot pain is often enigmatic. A high percentage of such complaints of limb pain in children resolve without any specific etiology being determined or any specific treatment being rendered. Knowing this, a common tendency can be to "wait it out" to see if symptoms of pain will resolve before undergoing a thorough evaluation of possible causes. If the pediatrician has had scanty training in orthopedic problems, as is often the case, a systematic evaluation can be even more difficult to undertake. As is true for any symptom complex, careful assessment depends on a knowledge of the anatomy and development of the child's foot, the common signs of usual problems, and a confidence in the ability to separate structural problems for further work-up from functional problems which can be managed symptomatically without great concern. This differentiation can be facilitated with a systematic approach. The evaluation of the child with foot pain begins with a history and physical examination. In taking the history, question the child if possible. On occasion, a parent may give the physician a history he believes the physician expects to hear, and this may be especially true when a child has flat feet. Unfortunately, even cooperative children often fail to recall
*Associate
Professor, Department of Orthopedics, College of Medicine, University of Florida, Gainesville, Florida
Pediatric Clinics of North America-Vol. 33, No.6, December 1986
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stepping on a foreign body, so that the absence of a positive history is of relative value only. The patient should be asked to localize the area of pain by pointing to it with one finger and to describe the nature of the pain as best he can (does it ache, stab, or hurt when bearing weight, is it relieved by rest, how often does it hurt?). It is helpful to know if the pain causes any restrictions of usual activities. Are there any indications of a systemic process (e.g., fever, malaise, or multiple other joints involved)? What measures have been taken to alleviate the pain? Has the child been seen by another physician, podiatrist, or a chiropractor? After taking the history, the physician will have an idea of the location and severity of the pain and whether it is the patient's problem or the parents'. The feet are then examined, and the approach must vary depending on whether the child is old enough to cooperate. If the child is uncooperative, the feet are first inspected in a non-weight-bearing position, as occasionally the pathology is obvious (ingrown toenail). The young child is best examined while seated in his mother's lap if cooperation is hard to obtain. Active motion can be assessed by tickling the foot and observing. The foot is examined by palpation, determining whether it is supple, by passively manipulating the feet to eliminate contracture or fixed deformity. One should never deliberately palpate for tenderness until all other aspects of the examination have been performed, and suspected areas of localized tenderness should always be the last portion of the examination other than gait observation. (Gait should be observed during any spontaneous motion of the young child.) For a systematic examination, after the non-weight-bearing portion has been completed, the child is placed in a standing position and observed during attempts to walk. Painful sites can be suspected from the part of the foot the child tries to protect. (Does he toe walk or heel walk?) If a child who complains of foot pain has no difficulty walking barefoot, either there is no problem or the shoes must be suspected. Compare the width of the shoe to the width of the foot. Shoes of inadequate width are one of the more common sources of pain in this age group. Radiographs are then obtained unless the examination indicated a definite cause for the patient's pain that would not be further clarified by radiographic studies, such as improper shoe wear. The approach can be more direct in the cooperative child who can relate a more accurate history and indicate the site of pain. The examination should still include inspection of the foot, palpation for localized tenderness, recording active and passive range of motion, and observation of the child standing and walking. The shoes should be inspected in the same manner as in the younger child. If radiographs are to be made, our routine is to obtain weight-bearing anteroposterior and lateral views of the foot and an oblique non-weight-bearing view. The oblique view should be included since occult fractures are sometimes evident on these views, and it is often the only standard view on which one can detect certain bony anomalies of the foot to be described later. If the problem is in the region of the ankle joint, separate views of the ankle must also be included. The CT scan has been very helpful in the detection of nonmetallic foreign bodies and is of occasional value in structural deformities.
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Table 1. Common Causes of Foot Pain in Children Extrinsic Ill-fitting shoes (ingrown toenail) Foreign body Structural Hypermobile Hat foot with tight heel cord Peroneal spastic Hat foot (tarsal coalition) Accessory navicular (prehallus) Pes cavus Osteochondroses (?) "Relaxed" Hat foot (?) InHammatory Osteomyelitis Juvenile rheumatoid arthritis ORA) Rheumatic fever Trauma Stress fracture Fractures Sprains (adolescents) Achilles tendonitis Tumors Osteoid osteoma Ewing's sarcoma SynOVial sarcoma
It is not unusual, however, after complete evaluation, that the etiology cannot be determined. As in so many instances in clinical practice, the pediatrician must depend on hislher judgment to aid in deciding whether to refer the patient. If a careful clinical and radiographic examination has not uncovered a cause of the pain, a period of observation is a logical course to follow. In this case, our approach is to follow the patient's progress with periodic reevaluations until either the problem has resolved or the etiology has become apparent. The more common causes of foot pain in children are outlined in Table 1. Table 2 indicates which conditions are more common in different age groups.
Table 2. Probable Causes of Foot Pain by Age AGES
0 TO 6 YEARS
Ill-fitting shoes Foreign body Occult fracture Osteomyelitis JRA (if other joints involved) Rheumatic fever (Hypermobile Hat foot)
AGES
6
TO
12 YEARS
Ill-fitting shoes Foreign body Accessory navicular Occult fracture Tarsal coalition (peroneal spastic Hat foot) Ingrown toenail Ewing's sarcoma (Hypermobile Hat foot)
AGES
12 TO 19 YEARS
Ill-fitting shoes Foreign body Ingrown toenail Pes cavus Hypermobile Hat foot with tight tendo Achillis Ankle sprains Stress fracture Ewing's sarcoma Synovial sarcoma
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EXTRINSIC CAUSES Ill-fittings shoes contribute much to foot misery, which may commence almost as soon as the infant is fitted with his first pair of shoes. "Corrective shoes" used for the treatment of clubfoot, metatarsus varus, or rotational problems can result in areas of increased pressure, especially if the deformity is not flexible. An infant can express discomfort only by irritability and fussiness, and if the shoes are responsible, they should be removed instead of "breaking them in." If a foot with a rigid deformity is fitted with a stiff, nonyielding shoe, it is likely that pressure sores will develop (Fig. 1). Generally, casting is safer for correction of foot deformities, although shoes may be used to maintain correction in a flexible foot. Bleck, in an excellent review of the problems related to the shoeing of children, noted that the lasts of most corrective shoes are molded in such a manner that they would fit an adducted foot, but not a straight foot. 3 A tennis shoe was found to come closest to the straight outline of most children's feet. A child with a straight foot placed in a shoe with a swingin leather last was apt to complain of pain in the region of the little toe, where the shoe compressed the foot. Many shoes are of inadequate width in the forefoot, and with time, calluses and corns result. Nothing more than a change to a shoe with an adequate width across the forefoot is necessary. Often, tennis shoes fulfill this need better than styled leather shoes.
Figure 1. Full-thickness pressure sore in the great toe in a child treated with straight last shoes for a rigid metatarsus adduct us deformity. (Coutesy of Robert Hufft, M.D.)
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Figure 2, A, A cross section of the distal phalanx of the great toe, showing the relationship of the nail groove on the left and an inflamed soft tissue fold which overlaps the nail on the right. B, When the nails are trimmed by rounding off the edges, the hypertrophied and inflamed soft tissue fold can overlap the nail, and ingrowth at the distal margin will occur, C, The correct way to trim the nail is to leave the edges squared to ensure that the trimmed edge of the nail, even if curved in, will protrude distally past the soft tissue f(lld and ingrowth will not occur.
Ingrown toenails, surprisingly, are more common during the second decade of life than any other time, 12 The entity receives much less attention in the literature than it deserves and it is certainly worthwhile to be aware of simple preventive measures. The pediatrician can spare his patients a great deal of aggravation by informing them to square off the nail when trimming, rather than rounding the edges (Fig, 2). Ingrowth is enhanced when tight-fitting shoes compress the soft tissues about the nail. If ingrowth is minimal, proper toenail trimming, soaks, local hygiene, and the wearing of shoes of adequate width solve the problem. For chronically inHamed nails, removal of the ungual soft tissue fold, the nail margin and matrix, or both is usually done. However, if proper nail cutting is not done postoperatively, recurrence is usual (Fig. 3),
Figure 3, Chronically inflamed ingrown toenails after repeated unsuccessful minor surgical procedures are deformed and hypertrophied, Ingrowth and inflammation of the soft tissue folds are still present. Total excision of the nail, the nail matrix, anrl the tuft of the distal phalanx was necessary,
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Retained foreign bodies warrant referral to an orthopedist. Localization and removal can be frustrating and are best done under ideal operating room conditions. Foreign bodies that are not radiopaque can cause great difficulty. The advent of the widespread availability of the CT scan has been extremely helpful in the localization of some foreign bodies.
STRUCTURAL CAUSES
The role of the flat foot as a cause of symptoms has been controversial for years, and unfortunately remains controversial at present. It is currently accepted that most "relaxed" flat feet may truly be categorized as normal variants. The infant's foot typically has no arch as a result of a thick fat pad, which may persist for several years. The toddler's gait is characteristically wide based, with the feet well lateral to the center of gravity. This will accentuate a tendency towards external rotation and eversion of the foot. Barry and Scranton outlined three factors responsible for the tendency toward a decrease in planovalgus throughout the period of growth: (1) improving balance and increasingly fine motor control of the distal groups of the lower extremity (peroneals and the posterior tibial muscle); (2) normal joint hypermobility that peaks in children from 2 to 3 years of age; and (3) increasing ossification of the structures of the foot, providing greater rigidity to the bones of the weight-bearing tripod. I At present, however, there are no standard or objective measures by which one can define a pathologic "relaxed flat foot." The mechanics of a pathologic process that will produce symptoms in a particular relaxed flat foot are elusive. Although a child will infrequently present with a painful relaxed flat foot, dozens of radiographically and clinically identical feet may be seen on any given day with no apparent untoward effects. Painful flat feet are usually noted to have a plantarflexed talus on weight-bearing radiographs. (Many painless feet are identical in appearance.) Several inserts and modifications have been described, but most present writings are skeptical regarding the value of such inserts. Although Bleck and Berzins described radiographic improvement with the use of an individually molded orthosis in the treatment of flexible pes valgus with the plantarflexed talus, the results were short term and there is no documented natural history with which to compare. 4 Another study found that symptoms were lessened with a molded insert, but no structural changes could be documented over a 2-year period. 15 In the very small subset of relaxed flat feet that are symptomatic, support of the arch by an individually molded orthosis seems to be very helpful. The length of treatment needed is arbitrary. I have empirically used a molded orthosis until the child outgrows it, and then allowed a trial of normal shoe wear (Fig. 4). Usually, there is no recurrence of symptoms. There is no evidence that a relaxed flat foot in a child is a precursor of a painful flat foot in the adult. A significant portion of the world's population is flatfooted, without any ill effects. 16 When one is faced with a child with a flatfooted appearance and complaining of foot pain, there are three conditions that should be sought as a possible etiology, especially in a child in the preadolescent growth
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Figure 4. A and B, Clinical appearance of a two-year-old child with a complaint of right foot pain, more pronounced at the end of the day and aggravated by activity. Examination revealed increased pronation in genu valgum on the right with synovial thickening of the right ankle joint. C, Radiographic appearance of "relaxed flat foot with plantarflexed talus." A short leg walking cast with the foot molded into a neutral position was applied on a trial basis. When this proved effective in relieving symptoms, a molded support was prescribed with good results.
spurt or older. Coalition of the bones in the hind foot is a relatively common cause of "painful flat foot" in the 8- to 16-year-old age group.5 This condition has a definite hereditary component. Calcaneal navicular coalition, easily identified on the oblique radiograph, is the most common symptomatic coalition. Feet thus affected will be noted to have a definitely decreased range of motion in eversion and inversion, and referral to an orthopedist is warranted. Attempts to invert feet with a symptomatic coalition are usually resisted by the patient with contraction and spasm of the peroneals (everters), thus the older term "peroneal spastic flat foot" (Fig. 5). The coalition is actually present between the cartilaginous anlages of the tarsal bones at birth but does not become symptomatic until the bones become more ossified and rigid, usually late in childhood. If the coalition is excised before secondary changes occur in the foot, good results can be expected. Another cause of painful flat feet was described in a classic paper by Harris and Beath, who studied 3619 Canadian Army recruits. 8 They described a condition, "hypermobile flat feet with short tendo Achillis,"
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Figure 5. Clinical appearance of a sixteen-year-old boy with left foot pain. Any attempts to manipulate the left foot from the pronated, everted position noted in this photograph resulted in pain and contraction of the peroneal muscle group. This boy was noted to have a calcaneal navicular coalition.
which in its severe form affected one out of every 145 men examined. The diagnosis is based on clinical evaluation. When being examined for contracture of the heel cord, the patient should be supine and the knee extended. With the foot everted (pronated), motion between the joints of the hind foot can glide, allowing apparent additional dorsiflexion at the ankle. This is not true dorsiflexion, however. Inverting (turning in) the foot "locks" the hind foot and attempted dorsiflexion of the ankle with the foot in this position yields a true picture of the amount of actual dorsiflexion possible (Fig. 6). If the ankle and foot cannot be dorsiflexed to a position 90° to that of the leg with the foot supinated, the joints of the hind foot must compensate for this contracture by becoming "hypermobile." With time, symptoms may develop either in the foot or the calf. Although not described in the original article, many orthopedists prescribe heel cord stretching exercises for treatment of this condition, especially in the childhood years. 17 A significant number of children presenting with foot or calf pain during the preadolescent growth spurt can be found to have relative contracture of the heel cord, probably secondary to a transient imbalance of length between the bone and the muscle-tendon unit. Stretching exercises are very helpful, and operative intervention is rarely needed. It is possible that the clinical entity of a "hypermobile" flat foot with tight tendo Achillis is also related to the so-called Sever's disease, considered to be an apophysitis of the growth center of the calcaneus (Fig. 7). The radiographic appearance of this growth center generally is quite variable, and again, diagnosis is made primarily on clinical assessment. Tenderness
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Figure 6. Hypermobile flat feet with short tendo Achillis. A, With the foot inverted, movement is entirely at the ankle joint, and the foot cannot be completely dorsiflexed to neutral. B, With eversion of the foot, further apparent dorsiflexion is possible but occurs in the joints of the hindfoot, not the ankle. C, The difference in apparent mobility of the foot when tested in inversion and eversion. (From Harris, R. 1., and Beath, T.: Hypermobile flat foot with tendo Achillis. J. Bone Joint Surg., 30A:121, 1948; with permission.)
over the calcaneal apophysis or the insertion of the heel cord is of primary importance. Although an elevated cushion in the shoe can help alleviate symptoms during activity, heel cord stretching should also be done to maintain range of motion at the ankle joint. A final variant of "flat foot" that may be productive of symptoms is the "accessory navicular." A prominence overlying the navicular, the bone palpable just distal to the medial malleolus, signals this condition (Fig. 8). Although symptoms referable to this area have commonly been regarded as secondary to the pull of the posterior tibial ten dOl} on the accessory
Figure 7. A normal appearance of the calcaneal apophysis. There were no symptoms in this foot. The sclerosis and fragmentation of the apophysis does not necessarily indicate Sever's disease. (From Rockwood, C. A., Wilkins, K. E., and King, R. E. (eds.): Fractures in Children. Philadelphia, J. B. Lippincott, 1984, p. 1101; with permission.)
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Figure 8. A nine-year-old girl with the complaint of painful feet, aggravated with shoe wear. The prominence of the navicular, just distal to the medial malleolus, heralds the "accessory navicular." The pain was aggravated by active inversion of the foot against resistance, placing; tension on the posterior tibial tendon. Although the navicular was clinically prominent, no accessory navicular was evident radiographically.
bone, more recent evidence indicates that accessory bone per se need not necessarily be present for this symptom complex to appear. It seems to be more related to the prominence of the navicular, with pressure against the shoe responsible for local symptoms, and then attenuated insertion of the posterior tibial tendon at this level responsible for the pain with activity. In any event, removal of the bony prominence and allowing the posterior tibial tendon to adhere to the underlying bony bed following excision of
Figure 9. Clinical appearance of cavus feet. Notice the clawing of the toes and the posture of the foot, with. weight bearing entirely on the heel pad and the metatarsal heads. Calluses can develop under bony prominences.
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the prominence seems to be very successful in relieving symptoms. 17 The accessory navicular is found in about 50 per cent of all feet, but the majority are asymptomatic. 17 The presence of an accessory navicular without symptoms is not an indication for any treatment. Although cavus (high-arch) feet have not received the widespread notoriety of the flatfoot, they are generally more symptomatic and a much more significant problem for the patient (Fig. 9). Neurologic disorders, especially spinal dysraphism, Charcot-Marie-Tooth disease, or Friedreich's ataxia, should be suspect, especially when the cavus is progressive or asymmetric. II With localized areas of weight bearing (as opposed to the flat foot, where the load is shared by a large portion of the plantar surface), calluses under the metatarsal heads are common, as are claw toes. Shoe correction with metatarsal pads or bars may assist in relief, but surgical intervention usually is eventually required. The management of these feet can be difficult, but it is probably well to involve the orthopedist relatively early in the care of cavus feet. Again, it is difficult to overemphasize the relationship of cavus feet to neurologic disorders. The osteochondroses (avascular necrosis) of the bones of the foot have been felt to be a source of pain. Often the ostechondritic process is an incidental radiographic finding and is not symptomatic. 9 Osteochondrosis of the calcaneus (Sever's disease) has already been mentioned. The other bone in the foot commonly affected by this type of process is the tarsal navicular, known as Kohler's disease, more common in early childhood (Fig. 10). Most often, discovery of this process is incidental. The long-term outlook for Kohler's disease is extremely benign. A less common, and less benign, osteochondrosis involves the head of the second metatarsal and is known as Freiberg's infarction. Treatment of this entity is more difficult, and the long-term outlook is less positive. Fortunately, it is quite rare.
Figure 10. Kohler's disease in a seven-year-old boy showing collapse and condensation. (From Rockwood, C. A., Wilkins, K. E., and King, R. E. (eds.): Fractures in Children.
Philadelphia,
J. B. Lippincott, 1984, p. 1096; with permission.)
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INFLAMMATORY CAUSES Septic arthritis rarely involves the ankle or foot as a primary focus, except with direct contamination by a foreign body. Osteomyelitis, however, can involve the foot, especially the os calcis and talus. This condition usually presents with fever and inability to walk, with localized swelling in the hind foot. Involvement of the foot alone in systemic conditions is unusual, and this fact can be helpful in differentiating an infection from juvenile rheumatoid arthritis or acute rheumatic fever. It is also unlikely that a unilateral inflammatory process is related to a systemic cause, but bilateral involvement should mandate a careful systemic work-up. Bone scanning is often helpful prior to radiographic changes of osteomyelitis. Bone aspiration or blood cultures are necessary to establish the identity of the offending organism. A puncture wound of the foot may cause osteomyelitis secondary to Pseudomonas, which often can appear more indolently. Any child stepping on a puncture wound should be less reluctant to bear weight by 3 to 5 days after injury. If pain or tenderness increases after this time, referral to an orthopedist is warranted, as surgical drainage is most likely needed. If surgical drainage is delayed longer than 2 weeks, long-term results are impaired. 8 Brodie's abscess is an abortive, subacute form of osteomyelitis commonly involving the distal tibia and possibly involving the small bones of the foot. Adolescent males are particularly susceptible and sustain an incidence five times greater than the general population. The sclerotic bony wall of these lesion.s inhibits the flow of systemic antibiotics, and surgical excision is indicated.
TRAUMATIC CAUSES With the presence of the distal tibial epiphysis in the growing child, and the relative weakness of this structure compared with bone and ligaments, the growth plate is generally first to fail with stress. It is well to remember this when evaluating what might appear to be an ankle sprain and obtain the appropriate radiographs, as ankle sprains in children are unusual. A more complete discussion of epiphyseal injuries is available elsewhere in this volume. The adolescent with a protracted period of symptoms following what seems to be an uncomplicated ankle sprain may have sustained an osteochondral injury of the talus, and repeat ankle radiographs should be made for any sprained ankle that does not resolve as expected (Fig. 11).2 This condition warrants referral to an orthopedist. In the adolescent, stress fractures can occur, especially when the patient undergoes a sudden increase in physical activity, such as the start of track season. 6 The hallmark of these injuries is localized bony pain with a negative initial radiograph, which only shows changes at 10 to 14 days when fracture callus or resorption is noted (Fig. 12). These injuries, however, are uncommon under the age of 12 or 13 years, and most commonly involve the second metatarsal. Symptoms of stress fractures often subside by the time of positive radiographic findings, and treatment
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Figure llA-C. A thirteen-year-old girl with ankle pain following a "sprain." Osteochondritis dissecans of the talus is noted and is most easily seen on the oblique view. (From Rockwood, C. A., Wilkins, K. E., and King, R. E. (eds.): Fractures in Children. Philadelphia, J. B. Lippincott, 1984, p. 1070; with permission.)
Figure 12. Painful second metatarsal of about two weeks' duration in a sixteen-year-old boy. A, Early callus. B, Residual callus three months later. (From Rockwood, C. A., Wilkins, K. E., and King, R. E. (eds.): Fractures in Children. Philadelphia, J. B. Lippincott, 1984, p. 1090; with permission.)
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up to this point is expectant. If the diagnosis is suspected and the patient is unable to walk, casting is probably best, and certainly does no harm even if the suspicion of stress fracture is not confirmed. Avulsion of the base of the fifth metatarsal, the prominence on the lateral side of the midfoot, is common with violent inversion of the foot. Sometimes this injury can be confused radiographically with a normal accessory bone, but clinical examination should make the differentiation between fracture and accessory bone quite ~imple. Achilles tendonitis is often seen in the same type of patient who is subject to stress fracture and is probably an "overuse" syndrome, resulting in small partial tears of the tendon. The condition is diagnosed by a localized tenderness in the tendon-differentiated by palpation from bony tenderness in the calcaneus itself, which is a different entity. Treatment of tendonitis consists of rest, immobilization, or a combination of the two. Local injections of steroid into the tendon should never be done because steroids weaken the tendon while improving symptoms and increase the chances of subsequent complete rupture.
TUMORS Tumors of the feet are rare in children, although they occur with enough frequency that one cannot be comfortable in excluding them from a differential diagnosis. The benign osteoid osteoma can affect the small bones of the foot, causing a dull pain, especially at night. Surgical excision is curative. In general, it is not particularly important for the pediatrician to be familiar with the unusual benign bone tumors in this area, but it is important to be aware that Ewing's sarcoma and synovial sarcoma, both tumors with a poor prognosis, often involve the foot. 7, 14 Ewing's tumor can involve a somewhat younger age group, whereas synovial sarcoma has a predilection for men in their late twenties. The important aspect in diagnosis is not to ignore persistent pain or swelling.
SUMMARY A general approach to the child with foot pain has been described. In that the pediatrician is so often the recipient of parent's questions about children's shoes, he or she should be aware of problems relating to poorly fitting shoes, probably the most common source of complaints of foot pain in children. With a systematic approach, the pediatrician is very capable of managing the majority of such complaints.
REFERENCES 1. Barry, R. J., and Scranton, P. E.: Flat feet in children. Clin. Orthop., 181:68, 1983, 2. Berndt, A. L., and Harty, M.: Transchondral fractures (osteochondritis dissecans) of the talus. J. Bone Joint Surg., 41A:988, 1959. 3. Bleck, E. E.: The shoeing of children-sham or science. Dev, Med. Child Neurol., 13:188, 1971.
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4. Bleck, E. E., and Berzins, V. J.: Conservative management of pes valgus with plantar flexed talus, flexible. Clin. Orthop., 122:85-94, 1977. 5. Cowell, H. R., and Elener, V.: Rigid painful flatfoot secondary to tarsal coalition. Clin. Orthop., 177:54, 1983. 6. Devas, M. D.: Stress fractures in children. J. Bone Joint Surg., 45B:.528, 1964. 7. Enneking, W. E.: Musculoskeletal Tumor Surgery. New York, Churchill Livingstone, 1983. 8. Green, N. E., and Bruno, J.: Pseudomonas infection of the foot after puncture wounds. South. Med. J., 73:146, 1980. 9. Gross, R. H.: Fractures and dislocations of the foot. In Rockwood, C. A., Wilkins, K. E., and King, R. E. (eds.): Fractures in Children. Philadelphia, J. B. Lippincott, 1984. 10. Harris, R. I., and Beath, T.: Hypermobile flat foot with short tendo Achilles. J. Bone Joint Surg., 30A:116, 1948. 11. James, C. C. M., and Lassman, L. P.: Spinal dysraphism: The diagnosis and treatment of progressive lesions in spina bifida occulta. J. Bone Joint Surg., 44B:828, 1962. 12. Lloyd-Davies, R. W., and Brill, G. C.: The etiology and out-patient management of ingrowing toenails. Br. J. Surg., 50:592, 1963. 13. Mann, R. A.: DuVries' Surgery of the Foot. St. Louis, C. V. Mosby Co., 1978. 14. Maroteaux, P.: Bone Diseases of Children. Philadelphia, J. B. Lippincott, 1979. 15. Mereday, C., Dolan, C. M. E., and Lussicin, R.: Evaluation of the University of California Bromeihan's Laboratory shoe insert in "flexible" pes planus. Clin. Orthop., 82:45,19.72. 16. Stewart, S. E.: Human gait and the human foot. An ethnological study of flatfoot. Part I. Clin. Orthop., 70:111, 1970. 17. Sullivan, J. A., and Miller, W. A.: The relationship of the accessory navicular to the development of the flat foot. Clin. Orthop., 144:233, 1979. 18. Tachdjian, M. 0.: The Child's Foot. Philadelphia, W. B. Saunders, 1985.
Department of Orthopedics University of Florida Box J-246 JHM Health Center Gainesville, Florida 32610
Common Orthopedic Problems
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Foot Pain in Children Richard H. Gross, M.D. *
Foot pain in children is not an unusual complaint. The evaluation of such a complaint, however, is often confounded by the fact that most pediatricians have had little exposure to this type of problem during their training. In addition, there are divergent opinions by recognized authorities on the symptomatology and management of such common problems as the pronated foot. The purpose of this paper is to outline an approach to the child with foot pain and to offer suggestions for the management of the more common problems.
CLINICAL EVALUATION The evaluation of a child with foot pain is often enigmatic. A high percentage of such complaints of limb pain in children resolve without any specific etiology being determined or any specific treatment being rendered. Knowing this, a common tendency can be to "wait it out" to see if symptoms of pain will resolve before undergoing a thorough evaluation of possible causes. If the pediatrician has had scanty training in orthopedic problems, as is often the case, a systematic evaluation can be even more difficult to undertake. As is true for any symptom complex, careful assessment depends on a knowledge of the anatomy and development of the child's foot, the common signs of usual problems, and a confidence in the ability to separate structural problems for further work-up from functional problems which can be managed symptomatically without great concern. This differentiation can be facilitated with a systematic approach. The evaluation of the child with foot pain begins with a history and physical examination. In taking the history, question the child if possible. On occasion, a parent may give the physician a history he believes the physician expects to hear, and this may be especially true when a child has flat feet. Unfortunately, even cooperative children often fail to recall
*Associate
Professor, Department of Orthopedics, College of Medicine, University of Florida, Gainesville, Florida
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stepping on a foreign body, so that the absence of a positive history is of relative value only. The patient should be asked to localize the area of pain by pointing to it with one finger and to describe the nature of the pain as best he can (does it ache, stab, or hurt when bearing weight, is it relieved by rest, how often does it hurt?). It is helpful to know if the pain causes any restrictions of usual activities. Are there any indications of a systemic process (e.g., fever, malaise, or multiple other joints involved)? What measures have been taken to alleviate the pain? Has the child been seen by another physician, podiatrist, or a chiropractor? After taking the history, the physician will have an idea of the location and severity of the pain and whether it is the patient's problem or the parents'. The feet are then examined, and the approach must vary depending on whether the child is old enough to cooperate. If the child is uncooperative, the feet are first inspected in a non-weight-bearing position, as occasionally the pathology is obvious (ingrown toenail). The young child is best examined while seated in his mother's lap if cooperation is hard to obtain. Active motion can be assessed by tickling the foot and observing. The foot is examined by palpation, determining whether it is supple, by passively manipulating the feet to eliminate contracture or fixed deformity. One should never deliberately palpate for tenderness until all other aspects of the examination have been performed, and suspected areas of localized tenderness should always be the last portion of the examination other than gait observation. (Gait should be observed during any spontaneous motion of the young child.) For a systematic examination, after the non-weight-bearing portion has been completed, the child is placed in a standing position and observed during attempts to walk. Painful sites can be suspected from the part of the foot the child tries to protect. (Does he toe walk or heel walk?) If a child who complains of foot pain has no difficulty walking barefoot, either there is no problem or the shoes must be suspected. Compare the width of the shoe to the width of the foot. Shoes of inadequate width are one of the more common sources of pain in this age group. Radiographs are then obtained unless the examination indicated a definite cause for the patient's pain that would not be further clarified by radiographic studies, such as improper shoe wear. The approach can be more direct in the cooperative child who can relate a more accurate history and indicate the site of pain. The examination should still include inspection of the foot, palpation for localized tenderness, recording active and passive range of motion, and observation of the child standing and walking. The shoes should be inspected in the same manner as in the younger child. If radiographs are to be made, our routine is to obtain weight-bearing anteroposterior and lateral views of the foot and an oblique non-weight-bearing view. The oblique view should be included since occult fractures are sometimes evident on these views, and it is often the only standard view on which one can detect certain bony anomalies of the foot to be described later. If the problem is in the region of the ankle joint, separate views of the ankle must also be included. The CT scan has been very helpful in the detection of nonmetallic foreign bodies and is of occasional value in structural deformities.
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Table 1. Common Causes of Foot Pain in Children Extrinsic Ill-fitting shoes (ingrown toenail) Foreign body Structural Hypermobile Hat foot with tight heel cord Peroneal spastic Hat foot (tarsal coalition) Accessory navicular (prehallus) Pes cavus Osteochondroses (?) "Relaxed" Hat foot (?) InHammatory Osteomyelitis Juvenile rheumatoid arthritis ORA) Rheumatic fever Trauma Stress fracture Fractures Sprains (adolescents) Achilles tendonitis Tumors Osteoid osteoma Ewing's sarcoma SynOVial sarcoma
It is not unusual, however, after complete evaluation, that the etiology cannot be determined. As in so many instances in clinical practice, the pediatrician must depend on hislher judgment to aid in deciding whether to refer the patient. If a careful clinical and radiographic examination has not uncovered a cause of the pain, a period of observation is a logical course to follow. In this case, our approach is to follow the patient's progress with periodic reevaluations until either the problem has resolved or the etiology has become apparent. The more common causes of foot pain in children are outlined in Table 1. Table 2 indicates which conditions are more common in different age groups.
Table 2. Probable Causes of Foot Pain by Age AGES
0 TO 6 YEARS
Ill-fitting shoes Foreign body Occult fracture Osteomyelitis JRA (if other joints involved) Rheumatic fever (Hypermobile Hat foot)
AGES
6
TO
12 YEARS
Ill-fitting shoes Foreign body Accessory navicular Occult fracture Tarsal coalition (peroneal spastic Hat foot) Ingrown toenail Ewing's sarcoma (Hypermobile Hat foot)
AGES
12 TO 19 YEARS
Ill-fitting shoes Foreign body Ingrown toenail Pes cavus Hypermobile Hat foot with tight tendo Achillis Ankle sprains Stress fracture Ewing's sarcoma Synovial sarcoma
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EXTRINSIC CAUSES Ill-fittings shoes contribute much to foot misery, which may commence almost as soon as the infant is fitted with his first pair of shoes. "Corrective shoes" used for the treatment of clubfoot, metatarsus varus, or rotational problems can result in areas of increased pressure, especially if the deformity is not flexible. An infant can express discomfort only by irritability and fussiness, and if the shoes are responsible, they should be removed instead of "breaking them in." If a foot with a rigid deformity is fitted with a stiff, nonyielding shoe, it is likely that pressure sores will develop (Fig. 1). Generally, casting is safer for correction of foot deformities, although shoes may be used to maintain correction in a flexible foot. Bleck, in an excellent review of the problems related to the shoeing of children, noted that the lasts of most corrective shoes are molded in such a manner that they would fit an adducted foot, but not a straight foot. 3 A tennis shoe was found to come closest to the straight outline of most children's feet. A child with a straight foot placed in a shoe with a swingin leather last was apt to complain of pain in the region of the little toe, where the shoe compressed the foot. Many shoes are of inadequate width in the forefoot, and with time, calluses and corns result. Nothing more than a change to a shoe with an adequate width across the forefoot is necessary. Often, tennis shoes fulfill this need better than styled leather shoes.
Figure 1. Full-thickness pressure sore in the great toe in a child treated with straight last shoes for a rigid metatarsus adduct us deformity. (Coutesy of Robert Hufft, M.D.)
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Figure 2, A, A cross section of the distal phalanx of the great toe, showing the relationship of the nail groove on the left and an inflamed soft tissue fold which overlaps the nail on the right. B, When the nails are trimmed by rounding off the edges, the hypertrophied and inflamed soft tissue fold can overlap the nail, and ingrowth at the distal margin will occur, C, The correct way to trim the nail is to leave the edges squared to ensure that the trimmed edge of the nail, even if curved in, will protrude distally past the soft tissue f(lld and ingrowth will not occur.
Ingrown toenails, surprisingly, are more common during the second decade of life than any other time, 12 The entity receives much less attention in the literature than it deserves and it is certainly worthwhile to be aware of simple preventive measures. The pediatrician can spare his patients a great deal of aggravation by informing them to square off the nail when trimming, rather than rounding the edges (Fig, 2). Ingrowth is enhanced when tight-fitting shoes compress the soft tissues about the nail. If ingrowth is minimal, proper toenail trimming, soaks, local hygiene, and the wearing of shoes of adequate width solve the problem. For chronically inHamed nails, removal of the ungual soft tissue fold, the nail margin and matrix, or both is usually done. However, if proper nail cutting is not done postoperatively, recurrence is usual (Fig. 3),
Figure 3, Chronically inflamed ingrown toenails after repeated unsuccessful minor surgical procedures are deformed and hypertrophied, Ingrowth and inflammation of the soft tissue folds are still present. Total excision of the nail, the nail matrix, anrl the tuft of the distal phalanx was necessary,
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Retained foreign bodies warrant referral to an orthopedist. Localization and removal can be frustrating and are best done under ideal operating room conditions. Foreign bodies that are not radiopaque can cause great difficulty. The advent of the widespread availability of the CT scan has been extremely helpful in the localization of some foreign bodies.
STRUCTURAL CAUSES
The role of the flat foot as a cause of symptoms has been controversial for years, and unfortunately remains controversial at present. It is currently accepted that most "relaxed" flat feet may truly be categorized as normal variants. The infant's foot typically has no arch as a result of a thick fat pad, which may persist for several years. The toddler's gait is characteristically wide based, with the feet well lateral to the center of gravity. This will accentuate a tendency towards external rotation and eversion of the foot. Barry and Scranton outlined three factors responsible for the tendency toward a decrease in planovalgus throughout the period of growth: (1) improving balance and increasingly fine motor control of the distal groups of the lower extremity (peroneals and the posterior tibial muscle); (2) normal joint hypermobility that peaks in children from 2 to 3 years of age; and (3) increasing ossification of the structures of the foot, providing greater rigidity to the bones of the weight-bearing tripod. I At present, however, there are no standard or objective measures by which one can define a pathologic "relaxed flat foot." The mechanics of a pathologic process that will produce symptoms in a particular relaxed flat foot are elusive. Although a child will infrequently present with a painful relaxed flat foot, dozens of radiographically and clinically identical feet may be seen on any given day with no apparent untoward effects. Painful flat feet are usually noted to have a plantarflexed talus on weight-bearing radiographs. (Many painless feet are identical in appearance.) Several inserts and modifications have been described, but most present writings are skeptical regarding the value of such inserts. Although Bleck and Berzins described radiographic improvement with the use of an individually molded orthosis in the treatment of flexible pes valgus with the plantarflexed talus, the results were short term and there is no documented natural history with which to compare. 4 Another study found that symptoms were lessened with a molded insert, but no structural changes could be documented over a 2-year period. 15 In the very small subset of relaxed flat feet that are symptomatic, support of the arch by an individually molded orthosis seems to be very helpful. The length of treatment needed is arbitrary. I have empirically used a molded orthosis until the child outgrows it, and then allowed a trial of normal shoe wear (Fig. 4). Usually, there is no recurrence of symptoms. There is no evidence that a relaxed flat foot in a child is a precursor of a painful flat foot in the adult. A significant portion of the world's population is flatfooted, without any ill effects. 16 When one is faced with a child with a flatfooted appearance and complaining of foot pain, there are three conditions that should be sought as a possible etiology, especially in a child in the preadolescent growth
FOOT PAIN IN CHILDREN
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Figure 4. A and B, Clinical appearance of a two-year-old child with a complaint of right foot pain, more pronounced at the end of the day and aggravated by activity. Examination revealed increased pronation in genu valgum on the right with synovial thickening of the right ankle joint. C, Radiographic appearance of "relaxed flat foot with plantarflexed talus." A short leg walking cast with the foot molded into a neutral position was applied on a trial basis. When this proved effective in relieving symptoms, a molded support was prescribed with good results.
spurt or older. Coalition of the bones in the hind foot is a relatively common cause of "painful flat foot" in the 8- to 16-year-old age group.5 This condition has a definite hereditary component. Calcaneal navicular coalition, easily identified on the oblique radiograph, is the most common symptomatic coalition. Feet thus affected will be noted to have a definitely decreased range of motion in eversion and inversion, and referral to an orthopedist is warranted. Attempts to invert feet with a symptomatic coalition are usually resisted by the patient with contraction and spasm of the peroneals (everters), thus the older term "peroneal spastic flat foot" (Fig. 5). The coalition is actually present between the cartilaginous anlages of the tarsal bones at birth but does not become symptomatic until the bones become more ossified and rigid, usually late in childhood. If the coalition is excised before secondary changes occur in the foot, good results can be expected. Another cause of painful flat feet was described in a classic paper by Harris and Beath, who studied 3619 Canadian Army recruits. 8 They described a condition, "hypermobile flat feet with short tendo Achillis,"
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Figure 5. Clinical appearance of a sixteen-year-old boy with left foot pain. Any attempts to manipulate the left foot from the pronated, everted position noted in this photograph resulted in pain and contraction of the peroneal muscle group. This boy was noted to have a calcaneal navicular coalition.
which in its severe form affected one out of every 145 men examined. The diagnosis is based on clinical evaluation. When being examined for contracture of the heel cord, the patient should be supine and the knee extended. With the foot everted (pronated), motion between the joints of the hind foot can glide, allowing apparent additional dorsiflexion at the ankle. This is not true dorsiflexion, however. Inverting (turning in) the foot "locks" the hind foot and attempted dorsiflexion of the ankle with the foot in this position yields a true picture of the amount of actual dorsiflexion possible (Fig. 6). If the ankle and foot cannot be dorsiflexed to a position 90° to that of the leg with the foot supinated, the joints of the hind foot must compensate for this contracture by becoming "hypermobile." With time, symptoms may develop either in the foot or the calf. Although not described in the original article, many orthopedists prescribe heel cord stretching exercises for treatment of this condition, especially in the childhood years. 17 A significant number of children presenting with foot or calf pain during the preadolescent growth spurt can be found to have relative contracture of the heel cord, probably secondary to a transient imbalance of length between the bone and the muscle-tendon unit. Stretching exercises are very helpful, and operative intervention is rarely needed. It is possible that the clinical entity of a "hypermobile" flat foot with tight tendo Achillis is also related to the so-called Sever's disease, considered to be an apophysitis of the growth center of the calcaneus (Fig. 7). The radiographic appearance of this growth center generally is quite variable, and again, diagnosis is made primarily on clinical assessment. Tenderness
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Figure 6. Hypermobile flat feet with short tendo Achillis. A, With the foot inverted, movement is entirely at the ankle joint, and the foot cannot be completely dorsiflexed to neutral. B, With eversion of the foot, further apparent dorsiflexion is possible but occurs in the joints of the hindfoot, not the ankle. C, The difference in apparent mobility of the foot when tested in inversion and eversion. (From Harris, R. 1., and Beath, T.: Hypermobile flat foot with tendo Achillis. J. Bone Joint Surg., 30A:121, 1948; with permission.)
over the calcaneal apophysis or the insertion of the heel cord is of primary importance. Although an elevated cushion in the shoe can help alleviate symptoms during activity, heel cord stretching should also be done to maintain range of motion at the ankle joint. A final variant of "flat foot" that may be productive of symptoms is the "accessory navicular." A prominence overlying the navicular, the bone palpable just distal to the medial malleolus, signals this condition (Fig. 8). Although symptoms referable to this area have commonly been regarded as secondary to the pull of the posterior tibial ten dOl} on the accessory
Figure 7. A normal appearance of the calcaneal apophysis. There were no symptoms in this foot. The sclerosis and fragmentation of the apophysis does not necessarily indicate Sever's disease. (From Rockwood, C. A., Wilkins, K. E., and King, R. E. (eds.): Fractures in Children. Philadelphia, J. B. Lippincott, 1984, p. 1101; with permission.)
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Figure 8. A nine-year-old girl with the complaint of painful feet, aggravated with shoe wear. The prominence of the navicular, just distal to the medial malleolus, heralds the "accessory navicular." The pain was aggravated by active inversion of the foot against resistance, placing; tension on the posterior tibial tendon. Although the navicular was clinically prominent, no accessory navicular was evident radiographically.
bone, more recent evidence indicates that accessory bone per se need not necessarily be present for this symptom complex to appear. It seems to be more related to the prominence of the navicular, with pressure against the shoe responsible for local symptoms, and then attenuated insertion of the posterior tibial tendon at this level responsible for the pain with activity. In any event, removal of the bony prominence and allowing the posterior tibial tendon to adhere to the underlying bony bed following excision of
Figure 9. Clinical appearance of cavus feet. Notice the clawing of the toes and the posture of the foot, with. weight bearing entirely on the heel pad and the metatarsal heads. Calluses can develop under bony prominences.
FOOT PAIN IN CHILDREN
1405
the prominence seems to be very successful in relieving symptoms. 17 The accessory navicular is found in about 50 per cent of all feet, but the majority are asymptomatic. 17 The presence of an accessory navicular without symptoms is not an indication for any treatment. Although cavus (high-arch) feet have not received the widespread notoriety of the flatfoot, they are generally more symptomatic and a much more significant problem for the patient (Fig. 9). Neurologic disorders, especially spinal dysraphism, Charcot-Marie-Tooth disease, or Friedreich's ataxia, should be suspect, especially when the cavus is progressive or asymmetric. II With localized areas of weight bearing (as opposed to the flat foot, where the load is shared by a large portion of the plantar surface), calluses under the metatarsal heads are common, as are claw toes. Shoe correction with metatarsal pads or bars may assist in relief, but surgical intervention usually is eventually required. The management of these feet can be difficult, but it is probably well to involve the orthopedist relatively early in the care of cavus feet. Again, it is difficult to overemphasize the relationship of cavus feet to neurologic disorders. The osteochondroses (avascular necrosis) of the bones of the foot have been felt to be a source of pain. Often the ostechondritic process is an incidental radiographic finding and is not symptomatic. 9 Osteochondrosis of the calcaneus (Sever's disease) has already been mentioned. The other bone in the foot commonly affected by this type of process is the tarsal navicular, known as Kohler's disease, more common in early childhood (Fig. 10). Most often, discovery of this process is incidental. The long-term outlook for Kohler's disease is extremely benign. A less common, and less benign, osteochondrosis involves the head of the second metatarsal and is known as Freiberg's infarction. Treatment of this entity is more difficult, and the long-term outlook is less positive. Fortunately, it is quite rare.
Figure 10. Kohler's disease in a seven-year-old boy showing collapse and condensation. (From Rockwood, C. A., Wilkins, K. E., and King, R. E. (eds.): Fractures in Children.
Philadelphia,
J. B. Lippincott, 1984, p. 1096; with permission.)
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INFLAMMATORY CAUSES Septic arthritis rarely involves the ankle or foot as a primary focus, except with direct contamination by a foreign body. Osteomyelitis, however, can involve the foot, especially the os calcis and talus. This condition usually presents with fever and inability to walk, with localized swelling in the hind foot. Involvement of the foot alone in systemic conditions is unusual, and this fact can be helpful in differentiating an infection from juvenile rheumatoid arthritis or acute rheumatic fever. It is also unlikely that a unilateral inflammatory process is related to a systemic cause, but bilateral involvement should mandate a careful systemic work-up. Bone scanning is often helpful prior to radiographic changes of osteomyelitis. Bone aspiration or blood cultures are necessary to establish the identity of the offending organism. A puncture wound of the foot may cause osteomyelitis secondary to Pseudomonas, which often can appear more indolently. Any child stepping on a puncture wound should be less reluctant to bear weight by 3 to 5 days after injury. If pain or tenderness increases after this time, referral to an orthopedist is warranted, as surgical drainage is most likely needed. If surgical drainage is delayed longer than 2 weeks, long-term results are impaired. 8 Brodie's abscess is an abortive, subacute form of osteomyelitis commonly involving the distal tibia and possibly involving the small bones of the foot. Adolescent males are particularly susceptible and sustain an incidence five times greater than the general population. The sclerotic bony wall of these lesion.s inhibits the flow of systemic antibiotics, and surgical excision is indicated.
TRAUMATIC CAUSES With the presence of the distal tibial epiphysis in the growing child, and the relative weakness of this structure compared with bone and ligaments, the growth plate is generally first to fail with stress. It is well to remember this when evaluating what might appear to be an ankle sprain and obtain the appropriate radiographs, as ankle sprains in children are unusual. A more complete discussion of epiphyseal injuries is available elsewhere in this volume. The adolescent with a protracted period of symptoms following what seems to be an uncomplicated ankle sprain may have sustained an osteochondral injury of the talus, and repeat ankle radiographs should be made for any sprained ankle that does not resolve as expected (Fig. 11).2 This condition warrants referral to an orthopedist. In the adolescent, stress fractures can occur, especially when the patient undergoes a sudden increase in physical activity, such as the start of track season. 6 The hallmark of these injuries is localized bony pain with a negative initial radiograph, which only shows changes at 10 to 14 days when fracture callus or resorption is noted (Fig. 12). These injuries, however, are uncommon under the age of 12 or 13 years, and most commonly involve the second metatarsal. Symptoms of stress fractures often subside by the time of positive radiographic findings, and treatment
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Figure llA-C. A thirteen-year-old girl with ankle pain following a "sprain." Osteochondritis dissecans of the talus is noted and is most easily seen on the oblique view. (From Rockwood, C. A., Wilkins, K. E., and King, R. E. (eds.): Fractures in Children. Philadelphia, J. B. Lippincott, 1984, p. 1070; with permission.)
Figure 12. Painful second metatarsal of about two weeks' duration in a sixteen-year-old boy. A, Early callus. B, Residual callus three months later. (From Rockwood, C. A., Wilkins, K. E., and King, R. E. (eds.): Fractures in Children. Philadelphia, J. B. Lippincott, 1984, p. 1090; with permission.)
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up to this point is expectant. If the diagnosis is suspected and the patient is unable to walk, casting is probably best, and certainly does no harm even if the suspicion of stress fracture is not confirmed. Avulsion of the base of the fifth metatarsal, the prominence on the lateral side of the midfoot, is common with violent inversion of the foot. Sometimes this injury can be confused radiographically with a normal accessory bone, but clinical examination should make the differentiation between fracture and accessory bone quite ~imple. Achilles tendonitis is often seen in the same type of patient who is subject to stress fracture and is probably an "overuse" syndrome, resulting in small partial tears of the tendon. The condition is diagnosed by a localized tenderness in the tendon-differentiated by palpation from bony tenderness in the calcaneus itself, which is a different entity. Treatment of tendonitis consists of rest, immobilization, or a combination of the two. Local injections of steroid into the tendon should never be done because steroids weaken the tendon while improving symptoms and increase the chances of subsequent complete rupture.
TUMORS Tumors of the feet are rare in children, although they occur with enough frequency that one cannot be comfortable in excluding them from a differential diagnosis. The benign osteoid osteoma can affect the small bones of the foot, causing a dull pain, especially at night. Surgical excision is curative. In general, it is not particularly important for the pediatrician to be familiar with the unusual benign bone tumors in this area, but it is important to be aware that Ewing's sarcoma and synovial sarcoma, both tumors with a poor prognosis, often involve the foot. 7, 14 Ewing's tumor can involve a somewhat younger age group, whereas synovial sarcoma has a predilection for men in their late twenties. The important aspect in diagnosis is not to ignore persistent pain or swelling.
SUMMARY A general approach to the child with foot pain has been described. In that the pediatrician is so often the recipient of parent's questions about children's shoes, he or she should be aware of problems relating to poorly fitting shoes, probably the most common source of complaints of foot pain in children. With a systematic approach, the pediatrician is very capable of managing the majority of such complaints.
REFERENCES 1. Barry, R. J., and Scranton, P. E.: Flat feet in children. Clin. Orthop., 181:68, 1983, 2. Berndt, A. L., and Harty, M.: Transchondral fractures (osteochondritis dissecans) of the talus. J. Bone Joint Surg., 41A:988, 1959. 3. Bleck, E. E.: The shoeing of children-sham or science. Dev, Med. Child Neurol., 13:188, 1971.
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4. Bleck, E. E., and Berzins, V. J.: Conservative management of pes valgus with plantar flexed talus, flexible. Clin. Orthop., 122:85-94, 1977. 5. Cowell, H. R., and Elener, V.: Rigid painful flatfoot secondary to tarsal coalition. Clin. Orthop., 177:54, 1983. 6. Devas, M. D.: Stress fractures in children. J. Bone Joint Surg., 45B:.528, 1964. 7. Enneking, W. E.: Musculoskeletal Tumor Surgery. New York, Churchill Livingstone, 1983. 8. Green, N. E., and Bruno, J.: Pseudomonas infection of the foot after puncture wounds. South. Med. J., 73:146, 1980. 9. Gross, R. H.: Fractures and dislocations of the foot. In Rockwood, C. A., Wilkins, K. E., and King, R. E. (eds.): Fractures in Children. Philadelphia, J. B. Lippincott, 1984. 10. Harris, R. I., and Beath, T.: Hypermobile flat foot with short tendo Achilles. J. Bone Joint Surg., 30A:116, 1948. 11. James, C. C. M., and Lassman, L. P.: Spinal dysraphism: The diagnosis and treatment of progressive lesions in spina bifida occulta. J. Bone Joint Surg., 44B:828, 1962. 12. Lloyd-Davies, R. W., and Brill, G. C.: The etiology and out-patient management of ingrowing toenails. Br. J. Surg., 50:592, 1963. 13. Mann, R. A.: DuVries' Surgery of the Foot. St. Louis, C. V. Mosby Co., 1978. 14. Maroteaux, P.: Bone Diseases of Children. Philadelphia, J. B. Lippincott, 1979. 15. Mereday, C., Dolan, C. M. E., and Lussicin, R.: Evaluation of the University of California Bromeihan's Laboratory shoe insert in "flexible" pes planus. Clin. Orthop., 82:45,19.72. 16. Stewart, S. E.: Human gait and the human foot. An ethnological study of flatfoot. Part I. Clin. Orthop., 70:111, 1970. 17. Sullivan, J. A., and Miller, W. A.: The relationship of the accessory navicular to the development of the flat foot. Clin. Orthop., 144:233, 1979. 18. Tachdjian, M. 0.: The Child's Foot. Philadelphia, W. B. Saunders, 1985.
Department of Orthopedics University of Florida Box J-246 JHM Health Center Gainesville, Florida 32610