Clubfoot treatment

The Ponseti method of serial plaster casts is used in the initial treatment of children with this foot deformity that affects 1 in 1000 live births. Treatment is best carried out soon after birth and was pioneered by an American surgeon called Dr Ignacio Ponseti. A cast is applied to the baby after gently stretching the foot and the procedure repeated weekly until the deformity has resolved. The technique requires great attention to detail to obtain success.

Dr Uglow visited The University of Iowa in July 2003 to meet with Dr Ponseti and gain valuable experience in the technique. He won a travel award from The British Society for Children’s Orthopaedic Surgery (BSCOS) to have the opportunity to assist him and has been using the Ponseti method since 2001. Dr Uglow is one of the leading UK surgeons using the method and is a member of the UK Clubfoot Consensus Group (UKCCG).

Flat feet

Many children have flat feet and almost all children have a flat foot until the age of approximately 4 years when the arch of the foot starts to develop. A few will have an arch earlier but many of those feet are not normal. If the arch has not appeared before the age of 10 years then it will not do so and the foot will always be flat.

A flat foot is not a problem unless it is painful or stiff. Many top level athletes have flat feet and have no problems with them. If aching or pain occurs then it may be helped with supportive foot wear or insoles (called orthotics). There are a number of conditions that cause pain and stiffness and these may need surgery to stop the pain and improve the shape of the foot.

Flat feet that cause problems often occur in children who have other conditions such as cerebral palsy and neuromuscular conditions. These are more likely to require surgery to help them but non-operative management should always be tried first.

Cavus (high arch) feet

Cavus is the term used to describe feet that have high arches. Patients with this type of foot shape have more problems than those with flat feet but are much less common. They are often found running in families and don’t always cause problems but can do so. The main features are as follows:

• Callus (hard skin) under the balls and outer border of the feet.

• Tilting in of the heel which causes excessive wear to the outside of the shoes and can cause frequent ‘giving way’ of the ankle.

This is often associated with a neurological cause and it is therefore important for any patient with high arched feet to be examined to determine if there is a problem with the nervous system. The deformity often gets worse over time when a nerve problem is the cause.

Treatment:

• Shoe adjustments and insoles (orthotics) can be very helpful.

• Surgery may be necessary to correct the foot shape and prevent recurrence of the problem.

• Tendon transfer surgery can prevent permanent bony deformity occurring.

• If deformity is permanent then surgery will involve cutting the bones as well as tendon transfer surgery.

Heel pain in children

Heel pain in children is really common and causes a lot of anxiety and disturbance from normal day to day and sporting activities. The causes are different from adults:

• Apophysitis (Sever’s disease) – pain from the growth plate of the heel.

• Haglund’s deformity – bumps on the back of the heel.

• Achilles tendon pain (occasionally)

I am often advised that a child has ‘plantar fasciitis’ but this is not true – the condition only occurs in adults. If you have been assessed by a health care professional and advised of this diagnosis in a child, then the practitioner may not be a expert in treating children.

Rarely there are other causes of heel pain such as:

• Cysts

• Stress fractures

• Tumours

• Subtalar arthritis

• Back pain – referred to the foot

Because of these causes it is always important to have a proper assessment of your child’s foot.

Apophysitis is inflammation of the growing part of the heel bone. It is caused by excessive activity, often on hard ground and is commonest in sports that involve impact on the heel which includes running & jumping as the main culprits. Soft heeled shoes are helpful and silicone insoles are usually very helpful. A reduction in levels of activity is often necessary to resolve the pain which can last for months. There is no surgery that can help this. In the long term, it never causes any long term problems which is reassuring, at least.

Haglund’s bumps can cause rubbing due to shoe wear over the prominence of the heel. Changing shoes to ones that don’t rub is all that is necessary but sometimes due to the site and size of the lump it is best to have them removed with a small operation. This cannot be done until the heel has virtually stopped growing at about the age of 13 yrs in girls and 15 yrs in boys.

Tarsal coalitions

Coalitions are abnormal joins between bones of the foot that should normally be separated by a joint. There are two common types and several very rare types. Coalitions actually are there at birth but present in middle childhood from about 10 years old. This is because the join between the bones begins as a flexible piece of tissue (fibrous or cartilage) and then turns into bone which becomes stiffer as the child grows. A mature coalition will allow no movement and the two bones that it joins act as one piece of bone.

The common two coalitions are calcaneonavicular and talocalcaneal.

An abnormal join can be seen between the heel bone (calcaneum) and the navicular hence – calcaneo-navicular

Children present with pain in the foot and stiffness. Activity usually makes the symptoms worse and sport is affected. Treatment is typically with an orthotic (insole) to help the position of the foot and pain relief and anti-inflammatories. Physiotherapy may help secondary problems such as shortening of the calf and other lower leg muscles.

Many patients will not be able to return to a desired level of activity and surgery can be very effective at solving the problem by removing the joining piece of bone. In some cases the join may be too big to remove and so other operations may be used to change the shape of the foot to help improve function.

Ankle pain in children

There are many causes of pain in the ankle and most are quite innocent and will settle without anything to worry about. Dr Uglow has extensive experience of dealing with children who have persistent ankle pain and there are plenty of things that can be done to help them depending on the true cause.

Possible causes are as follows:

• Foot deformity: excessive flat feet or cavis (high arch) feet

• Ankle sprains causing instability: following a sprain the joint may become unstable and be a cause of pain

• Ankle fracture

• Accessory bones: these are extra little bones that develop and can rub and cause pain (on either side of the joint)

• Impingement: pain that persists after an injury may be due to impingement.

• Posterior impingement (behind the ankle) is common in dancers

• OCD (osteochondral defect) This is where a small area of the surface of the joint gets damaged. This requires expert assessment and may need surgery.

• Synovitis: the lining of the joint can become inflamed and cause pain

• Arthritis: a joint can become inflamed and be the start of a more generalised arthritis

So there are many possibilities to explain your child’s pain. The most important thing is to have an accurate diagnosis made by an expert who deals with Children’s Orthopedics.