Children’s Conditions of the Foot and Ankle

Flatfoot in children or pediatric pes planus is one of the most common etiologies that parents will bring their children to see the podiatrist about. Pediatric flatfeet can be broadly divided into two classes: symptomatic vs asymptomatic flatfoot. When you visit your podiatrist they will ask a number of questions that will help determine which class of flatfoot your child has. If the child has no pain, is neurodevelopmentally normal, hitting normal milestones with development, no history of excessive tripping then they are considered to have a asymptomatic flatfoot and in most cases will just be monitored. If the child has pain to the feet, any history of neurological or developmental impairment, is not hitting their normal developmental milestones on time or have an excessive history of tripping then they may need further workup to rule out any other underlying etiologies. We commonly give these symptomatic pediatric flatfoot patients custom orthotics or AFO braces to help allow them to function normally and eliminate their pain.

The pictures above show how an orthotic device can hold the foot in the correct functional position and prevent excessive pronation of the foot or rolling in of the arch.

Child toe walking

Toe-walking is a condition that tends to occur in early childhood. Sometimes the child will start out toe-walking from the beginning but other times children will learn to toe walk over time. It is important with this condition to be evaluated as sometimes toe walking can be a sign of an underlying neuromuscular disorder. In many cases toe walking is simply a learned behavior in which the child needs to be conditioned not to perform the behavior any more. The risk of not treating toe walkers is that they will develop contractures to the achilles tendon and require surgery or serial casting to re-lengthen this tendon.

Ingrown toenails, also known as Onychocryptosis, are one of the most common pathologies that podiatrist treat. The first thing to realize about ingrown toenails is that they are not all created equal and so they are not all treated the same. There are different stages to ingrown toenails ranging from an irritated ingrown toenail to an infected ingrown toenail. The most important thing to remember is DON’T WAIT to come into the office if you think you have an ingrown toenail. There are treatment options when an ingrown toenail first presents that cannot be used if the ingrown toenail is more advanced.

An ingrown toenail happens when the nail curves and grows into the skin, usually at the sides of the nail. When the nail digs into the skin, it causes irritation and often leads to pain, redness, swelling, and warmth in the toe. If an ingrown nail causes a laceration, or cut, in the skin, it can become infected. Some signs of infection are drainage or pus, and a foul odor. Even if you don’t notice any pain, swelling, redness, or unusual warmth, an ingrown toenail can still become infected, and needs to be taken care of.

Depending on the severity of the ingrown toenail the nail may either be cut back with or without local anesthetic. Sometimes patients will need to be put on an oral antibiotic if the surrounding soft tissue is infected. After the nail border is removed the patient will be instructed to soak in Epsom salts and water daily and apply antibiotic ointment and a bandaid.

Causes:

The most common cause of ingrown toenails is cutting your toenails too short, or cutting them incorrectly. Improper trimming can damage the nail. The skin will fold over the nail, making the nail grow into the skin, or become “ingrown.” Other causes come from pressure or trauma, and in some cases, there may be a hereditary predisposition for ingrown toenails. Excessive pressure on the toenail, from shoes, or repeated kicking or running, can also cause the nails to dig into the skin. Trauma, such as stubbing your toe, or having a heavy object fall on your toe, can sometimes cause an ingrown toenail.

Wearing socks or shoes that are too tight, or too short, can cause ingrown toenails because of the pressure on the toes. Ingrown toenails can also be caused by fungal infections, or by losing a nail. Bone deformities of the toes can change the shape of toenails, and also lead to them becoming ingrown.

Treatment:

Home care:
Home treatment for ingrown toenails is strongly discouraged if an infection is suspected, or for those who have medical conditions such as diabetes, nerve damage in the foot, or poor circulation that put feet at high risk. If you don’t have an infection or any medical conditions affecting your feet, you can soak your foot in room-temperature water (adding Epsom’s salt if recommended by your doctor), and gently massage the side of the nail to help reduce the swelling. DO NOT attempt “bathroom surgery,” or to cut the toe out of the skin at all. Repeated cutting of the ingrown toenail can make condition worse over time. If your symptoms don’t improve with soaking or over time, see your podiatrist.

Physician care:
Oral antibiotics may be prescribed to help treat infection; however, antibiotics alone cannot cure an infected ingrown toenail. The infection will continue to return until the nail is fixed, and no longer digs into the skin. A minor surgical procedure can often be done in the office, to remove the nail and ease the pain. After applying a local anesthetic, the podiatrist removes the ingrown part of the nail. For nails that repeatedly become ingrown, there’s a more permanent option. The podiatrist can remove the nail matrix, the area responsible for nail production, and prevent further ingrown toenails. This procedure is still minor, and is often done in the office. The toe is wrapped in a light bandage after the procedure, and most people resume normal activity the next day, experiencing very little pain after surgery. If you’ve been prescribed an oral antibiotic, be sure to take all the medication even if your symptoms have improved.

Prevention:

Ingrown toenails can be prevented by properly trimming toenails, and by wearing appropriate footwear.

When trimming, cut toenails in a straight line, avoid rounding the nail, and don’t cut them too short. They should be long enough so that you can get your fingernail under the sides and end of the nail.

Wear shoes and socks that fit properly. Don’t wear shoes that are short or tight in the toe area. Also avoid shoes that are loose, because they can cause pressure on the toes, especially during running or brisk walking.

Warts of the foot, AKA plantar warts or verruca plantaris, are a viral infection caused by the Human Papillomavirus (HPV). Plantar warts can affected people of all ages but tend to be more common in adolescence or immunocompromised individuals. These lesions present as either a solitary wart or a cluster or warts called a mosaic wart. They tend to be painful with side to side compression, have an absence of skin lines through the lesion, and have small black dots in the center called “hyphae” which are actually dry blood contained within the capillaries of the wart. If you think you have a wart you should consult with your podiatrist right away as warts not only can multiply but can also spread from person to person by contact. When you come to the podiatry office your doctor will talk to you about the different treatment options for plantar warts including topical kerolytics (AKA cantharidin or salycyclic acid, the ingredient found in most over the counter medications), cryotherapy, or laser therapy.

The above picture depicts a plantar wart. Notice the absence of skin lines through the wart as well as the central hyphae. These clinical clues help determine that this lesion is a wart.

Calcaneal Apophysitis

Calcaneal Apophysitis (also known as Sever’s Disease) is a painful inflammatory condition that most commonly affects children aged 8-14. The inflammation in this condition is centered around the calcaneal growth plate (heel) and tends to cause symptoms such as heel pain and limping. The cause of this condition is increased tension on the growth plate from repetitive trauma and tugging of the achilles tendon on the insertion of the growth plate. There are many treatment options for calcaneal apophysitis including offloading the heels with gel heel pads, crutches or a walking boot as well as rest, NSAIDs and physical therapy.