Dr. John A. Schlechter - Pediatric Orthopedic Surgeon - Fracture Care, Sports Medicine and Arthroscopy for Children and Adolescents
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Dr. John A. Schlechter - Pediatric Orthopedic Surgeon - Fracture Care, Sports Medicine and Arthroscopy for Children and Adolescents: (714) 633-2111
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Dr. John A. Schlechter
Dr. John A. Schlechter - Pediatric Orthopedic Surgeon

Patient Info

Foot & Ankle

Iselin Disease :: Club foot :: High Arch (Cavus Foot) :: Achilles Tendon Bursitis
Congenital Vertical Talus :: Tarsal Coalition :: Tarsal tunnel syndrome :: Toe Deformities

Club foot

Club foot is a common foot deformity present at birth where in one or both the feet are turned towards an inward and downward position. It is more common in boys than girls. It is also called as talipes equinovarus.

Club foot is of two types:

  • Postural or positional club foot – This occurs as a result of abnormal positioning of the fetus in the mother's womb. The foot is flexible and can be moved to a near normal position after birth.
  • Rigid or fixed club foot – In rigid form, the foot is rigid or stiff as the muscles at the back of the lower leg become very tight.

Although club foot does not cause any pain, it can affect the physical appearance and the child's ability to walk. Children with club foot may have abnormal foot where,

  • Foot may be slightly smaller than the normal
  • The front of the foot may be twisted toward the other foot
  • Stiff muscles in the lower leg which may affect range of motion

The exact cause of clubfoot is unknown. Genetic and environmental factors may have a role in developing the condition. Other congenital malformations such as spina bifida may also cause club foot.

Treatment options include:

Stretching and Casting - It is also known as the Ponseti method. The foot is manipulated into a correct position and a cast is placed to maintain that position. Repositioning and recasting is repeated for every 1 to 2 weeks for 2 to 4 months, each time bringing the foot toward the normal position. After realignment of the foot, it is maintained through splinting with braces to keep the foot in the corrected position. The brace is worn for 3 months following which it is worn only at night for up to 3 years, to maintain the correction.

Club foot repair – It is surgical repair of the birth defect which involves lengthening or shortening the tendons (tissues that help attaches muscles to bones) of the foot.

Osteotomy – It is a surgical procedure where a part of the bone is cut to shorten or lengthen its alignment. The procedure involves removal of a wedge shaped bone located near the damaged joint and the remaining bones are joined together and secured using the staples or pins.

Fusion or arthrodesis – It is a surgical procedure where two or more bones are joined or fused together. Bone for fusion will be taken from other parts in the body. Metal pins or plates may be used to hold the bones in position.

High Arch (Cavus Foot)

High arch (cavus foot) is a condition in which the arch on the bottom of the foot that runs from the toes to the heel is raised more than normal. Because of this high arch, excessive weight falls on the ball and heel of the foot when walking or standing causing pain and instability. Children with neurological disorders or other conditions such as cerebral palsy, spina bifida, poliomyelitis, muscular dystrophy are more likely to develop cavus foot.  It may sometimes occur as an inherited abnormality.

The symptoms of cavus foot include one or more of the following:

  • Pain in the foot while walking, standing and running
  • Heel is tilted inwards leading to instability of the foot and ankle sprains
  • Callus formation on the ball and at outer edges  of the foot
  • Toes become bent (hammertoes) or clenched like a fist(claw toes)
  • Difficulty in wearing shoes
  • Foot length is shortened

Diagnosis of cavus foot is based on the family history and physical examination of the foot. X-ray of the feet may also be ordered to determine the condition.

Treatment

High arches that are flexible do not require any treatment. In cases where there is pain, shoe modifications such as an arch insert or support insole can help to relieve pain during walking. Custom orthotic devices can be given that fit into the shoe and provide stability and cushioning effect. Your doctor may recommend a brace to help keep the foot and ankle stable. In severe cases, surgery is performed to flatten the foot. Any coexisting nerve disorders are also treated.

Achilles Tendon Bursitis

Achilles tendon bursitis or retrocalcaneal bursitis is a condition that commonly occurs in athletes. It is a painful condition caused by swelling of bursa, a fluid-filled sac which is located at the back of the heel under the Achilles tendon. This retrocalcaneal bursa contains a lubricating fluid that acts as a cushion to reduce friction between muscle and bones. Achilles tendon is the large tendon that connects the calf muscles to the heel bone (calcaneous) and is used when you walk, run, and jump.

Achilles tendon bursitis is caused by overuse of the ankle which results in irritation and inflammation of the bursa. The common causes include too much of walking, jumping, or running, Achilles tendon bursitis can also occur in conjunction with Achilles tendinitis, inflammation of the Achilles tendon.

Children who suddenly increase their level of physical activity are at a higher risk of developing Achilles tendon bursitis.

The most common symptom is pain and tenderness at the back of the heel especially while walking or running. Pain increases when standing on tiptoes. In some cases, the skin at the back of the heel may become warm and red.

Your doctor may diagnose the condition based on the symptoms and physical examination of the ankle. Diagnostic tests such as X-ray and MRI may be required later on if the treatment does not improve the symptoms.

Treatment

The initial treatment for Achilles tendon bursitis includes

  • Restrict the activities that cause pain.
  • Apply ice on the injured area which will help to reduce the swelling. Ice should be wrapped on a cloth and applied rather than direct application.
  • Nonsteroidal anti-inflammatory medications may be given to reduce the inflammation and pain.
  • Custom heel wedges can be used to reduce the stress on the heel.
  • Physical therapy may be recommended which will help to restore and improve the flexibility and strength of the muscles, tendons, and joints around the ankle.
  • Corticosteroid injections may be injected into the bursa to reduce swelling and pain. You must ensure that your child does not over stretch the tendon after the injection as it may lead to Achilles tendon rupture.
  • If retrocalcaneal bursitis is associated with Achilles tendonitis, it may be necessary to immobilize the ankle for several weeks until healing takes place. This can be done by applying a cast on the ankle, which limits ankle movement and allows the tendon to rest.

Surgery is considered only when all non-surgical treatment fails to resolve pain and inflammation.  Bursectomy is a surgical procedure done to remove an inflamed or infected bursa.

Achilles tendon bursitis may be prevented by maintaining proper form during exercises. Ensure that your child does some warm up exercises before the start of any sports activity which may help prevent injury of the Achilles tendon.

Congenital Vertical Talus

Talus bone makes up the ankle joint, and navicular bone is a small bone found in the feet. Congenital vertical talus is a foot deformity in which the talus and navicular bones of the child’s feet are abnormally positioned. This leads to rigid flat foot with a rocker-bottom appearance. The hind foot points downwards to the floor while the forefoot points upwards. It is usually present at birth and can occur with other conditions such as arthrogryposis and spina bifida. The exact cause for congenital vertical talus is unknown. One of the studies suggests that the abnormal pressure placed on the foot while the fetus is inside the uterus can cause the deformity. Other school of thought suggests muscle imbalance as the cause for the deformity. In both cases, stiffness in the hind foot causes the forefoot to ride on top of the talus and destabilize the entire foot.

The sole of foot appears convex and the normal arch of the foot is reversed. There is a crease on the upper portion of the foot. A callous may form on the sole of the foot at the place where the protruding talus bone touches the ground. If it is left untreated, it can cause pain in the foot which makes wearing shoes difficult and the child starts walking with a "peg leg gait".

Treatment

This condition should be recognized and treated early because early, aggressive treatment gives better result. The treatment is started with manipulation and casting in order to stretch the foot. Surgery becomes necessary for complete correction of the deformity and should be performed before the age of two.

Surgery involves reduction of the dislocated bones of the foot and fusion of the joint between the talus and navicular bone. Achilles tendon or heel cord that has contracted may be lengthened. Complicated procedures such as fusing the talus to the bone in the heel may be required in older children.

Tarsal Coalition

Tarsal coalition is a developmental condition in which there is an abnormal connection between two or more of tarsal bones. Tarsal bones are calcaneus, talus, navicular, and cuboid bones that help in proper functioning of the foot.

Tarsal coalition can occur across a joint between talus and calcaneus (talocalcaneal coalition) in the foot or between calcaneus and navicular bones (calcaneonavicular coalition). An abnormal growth of bone cartilage and fibrous tissue causes pain and decreased range of motion of foot. It is an inherited disorder and occurs as a result of failure of differentiation of the cells that form tarsal bones during development of the fetus in the womb, infections, arthritis, or injury to the area. Your child will not have symptoms until 8 –16 years.

The symptoms of tarsal coalition may vary between each child and include the following:

  • Pain on the top of the foot
  • Flat feet
  • Muscle spasms
  • Rigidity or stiffness in the affected foot

Your pediatrician may ask you about your child's medical history followed by which a physical examination is done and an X-ray of the foot is taken. Other diagnostic tests such as MRI and CT scan are done to confirm the diagnosis and rule out other associated abnormalities.

Treatment

Several non-surgical and surgical treatment options are available for tarsal coalition. The objective of non-surgical method is to relieve pain and muscle spasm. Conservative approach includes custom made orthotics such as shoe inserts may be recommended to support the affected joint. Cortisone injection or an anesthetic injection gives temporary pain relief. Anti-inflammatory medications are given to reduce pain.

Your pediatrician may recommend surgery if pain persists even after conservative treatment. Surgery depends on the type, site of coalition and whether arthritis is involved. If there is no arthritis, surgery involves resection of the union between bones thereby allowing normal range of motion to occur. In some cases, surgery involves fusion of the affected joints so as to limit the range of motion and reduce pain.

After the surgery, a splint or cast may be recommended along with crutches to immobilize the foot and to prevent the foot from bearing weight while the healing happens. Your child can perform certain exercises that will help to restore the normal muscle tone and range of motion.

Tarsal tunnel syndrome

Tarsal tunnel is the gap that is formed between the underlying bones of the foot and the overlying tough fibrous tissue. Tarsal tunnel syndrome refers to a condition where the posterior tibial nerve that lies within the tarsal tunnel is compressed. The condition occurs when the tibial nerve is pinched.

Exact cause of the condition is not known but certain conditions such as fractures, bone spurs, ganglions, benign tumors, muscle impingement, or foot deformities are known to increase the risk of developing tarsal tunnel syndrome. Other medical conditions such arthritis can cause swelling of the joints that may compress the nerve. Scar tissue formed after an ankle injury and growth of abnormal blood vessels can press against the nerve resulting in compression.

Most children with tarsal tunnel syndrome complain of pain, numbness, and burning or tingling sensation at the bottom of the foot and heel.

Tarsal tunnel syndrome can be diagnosed by Tinel's test. Tinel's test is performed by tapping the posterior tibial nerve lightly which produces pain and other symptoms indicating tarsal tunnel syndrome.

Tarsal tunnel syndrome may be treated with conservative approaches which include:

  • Nonsteroidal anti-inflammatory medications to relieve pain and reduce swelling.
  • Corticosteroid injection that are injected into the area around the nerve to decrease the swelling.
  • Use orthotics, such as specially designed shoe inserts or change in foot wears will help to support the arch of the foot and take the tension off the tibial nerve.

Surgery is often considered a last resort only when conservative treatments fail to resolve the condition and provide symptomatic relief. Your doctor may perform tarsal tunnel release surgery to treat the condition. During this surgery an incision is made in the tarsal tunnel and the pressure on the tibial nerve is released.

Toe Deformities

Toes are the digits in your foot and are associated with walking, providing balance, weight-bearing and other activities. A variety of toe deformities occur in children's feet. They are as follows:

  • Hallux Valgus: Hallux valgus is a common toe deformity in which the child's great toe is shifted laterally and lies over the second toe. The first metatarsal bone is deviated towards the medial side causing a prominence over the medial aspect of the metatarsophalangeal (MTP) joint. A fluid filled sac (bursa) may form over this prominence which may result in a painful bunion caused by continuous irritation and inflammation. Foot pronation (flat feet) may sometimes be associated with this condition.

    The factors that cause hallux valgus include structural foot anomaly that may or may not be hereditary and use of narrow shoes that curl or fold the toes. Children having hallux valgus may not have any symptoms most of the times and do not require any treatment. Your doctor may advise shoes that have good amount of space for the toes and no heels. If there is flat foot then a shoe insert may help to prevent its progression. Surgery may be recommended only in severe cases.
  • Hammertoe: Hammertoe is a deformity in which there is downward bending of the middle joint of the toe or the proximal interphalangeal joint (PIP). Although it can affect the other toes, it most commonly affects the second toe. It may be present at birth or may result from wearing shoes that are too tight which forces the toe to bend forward. It causes no pain and does not require any specific treatment. Hammer toe can be treated by ensuring that your child wears well fitting shoes that has enough space for the toes to stretch.
  • Mallet Toe: Mallet toe refers to the downward bending of the third joint or distal interphalangeal joint (DIP) giving it a mallet-like appearance. Corns or calluses may develop over the deformity as a result of constant friction against the footwear. Mallet toe can be inherited or may develop from wearing shoes that are too tight or high-heeled.
  • Claw Toe: Claw toe is a rare deformity but occurs in association with cavus foot, Charcot-Marie-Tooth disease or myelomeningocele. It affects all the toe joints and results from hyperextension of the metatarsophalengeal (MTP joint or 1st joint) and flexion at the PIP (2nd joint), and DIP (3rd joint) joints. It results from altered structural anatomy and /or neurologic disorder that cause muscle imbalances.
  • Curly Toe: Curly toes are present at birth and affect the third, fourth and fifth toes of one or both the feet. It is caused by tightening of the tendon that runs below the toe which results in pulling of the tip of the toe under the next toe towards the sole. Your child may develop areas of hard skin on the sole of the foot and may have difficulty in selecting suitable shoes that fit properly.

    Generally, no treatment is needed if curly toes do not cause any symptoms but if the condition becomes severe and causes irritation, then surgery may be performed to release and transfer of toe flexor.
  • Polydactyly: It is a condition in which there is an extra digit present in the feet. The great toe or the fifth toe is usually affected. It may occur in association with other congenital anomalies or as an isolated problem. If the extra digit does not cause any problem, it may be left alone without any treatment. Surgical excision of the extra digit will be done in cases where there is an extra little or big toe that is prominent causing difficulty in wearing shoes. Surgery is usually done after the age of 9-12 months.
  • Syndactyly: Syndactyly is the presence of fused digits and may occur along with other congenital anomalies or as an isolated problem. It rarely causes any problems and does not need any treatment. The connection between two or more toes varies from a thin skin attachment to a bony attachment (synostosis) between the phalanges.
  • Bunionette (Tailor Bunion): Bunionette is less common and occurs at the fifth MTP joint. When this occurs, the fluid sac over the lateral side of the fifth MTP joint becomes prominent and inflamed causing pain. Padding is done to relieve the discomfort. If this does not help, surgical correction will be needed.

Click on the topics below to find out more from the Orthopaedic connection website of American Academy of Orthopaedic Surgeons.

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