Common Foot

Abnormalities
in Children
dr. Budiati Laksmitasari, SpKFR
What should a “General Practitioner” do?

If a child brought to your clinic by her/his parent who complain

about the child’s foot:

▰ Pain
▰ Abnormal posture
▰ Abnormal gait

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What should a “General Practitioner” know?

▰ Typical foot
▰ Typical growth of foot
▰ Typical gait in children
▰ Common foot abnormalities
▰ Role of a GP
▰ Role of PM&R

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Typical Foot

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 HUMAN FOOT: SMALL BUT COMPLEX

Consists of 26 Bones….
▰ 7 tarsal:
▻ Talus Hindfoot
▻ Calcaneus
▻ Navicular
▻ Cuboid Midfoot
▻ 3 cuneiform
▰ 5 metatarsal
Forefoot
▰ 14 phalangs
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Houglum PA, Bertoti DB. Brunstorm’s clinical kinesiology. 6th ed. Philadelphia: F.A. Davis; 2012. p. 474-532.
 HUMAN FOOT: SMALL BUT COMPLEX

… 33 Joints ….
▰ Main joints:
▻ Metatarsophalangeal (MTP)
▻ Tarsometatarsal (Lisfranc)
▻ Midtarsal/tarsal transversal
(Chopart)
▻ Subtalar

▰ Talocrural (ankle joint)

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Houglum PA, Bertoti DB. Brunstorm’s clinical kinesiology. 6th ed. Philadelphia: F.A. Davis; 2012. p. 474-532.
 HUMAN FOOT: SMALL BUT COMPLEX

…over 100 muscles, tendon, and ligaments…

▰ Foot muscles:
▻ Extrinsic muscles
▻ Intrinsic muscles

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Houglum PA, Bertoti DB. Brunstorm’s clinical kinesiology. 6th ed. Philadelphia: F.A. Davis; 2012. p. 474-532.
 HUMAN FOOT: SMALL BUT COMPLEX

… and plantar fascia

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Houglum PA, Bertoti DB. Brunstorm’s clinical kinesiology. 6th ed. Philadelphia: F.A. Davis; 2012. p. 474-532.
 FOOT AND ANKLE MOTION

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Houglum PA, Bertoti DB. Brunstorm’s clinical kinesiology. 6th ed. Philadelphia: F.A. Davis; 2012. p. 474-532.
 MORE RIGID VS MORE FLEXIBLE FOOT

▰ Pronation à more flexible

▰ Supination à more rigid

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Houglum PA, Bertoti DB. Brunstorm’s clinical kinesiology. 6th ed. Philadelphia: F.A. Davis; 2012. p. 474-532.
 MORE RIGID VS MORE FLEXIBLE FOOT

▰ Medial longitudinal arch:

▻ Load bearing
▻ Shock absorbent
▰ Factors keeping the foot arch:
▻ Ligaments
▻ Plantar fascia
▻ Muscles
▻ Bone structure
▰ Low arch à more flexible
▰ High arch à more rigid
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Houglum PA, Bertoti DB. Brunstorm’s clinical kinesiology. 6th ed. Philadelphia: F.A. Davis; 2012. p. 474-532.
Typical Growth of Foot

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 GROWTH OF FOOT IN CHILDREN:
VELOCITY

▰ The foot achieves adult length earlier than the

rest of the body
▰ Half of the adult length of the foot is achieved
between 12 and 18 months of age
▻ Half of adult height is achieved at 2 years
▻ Half of the lower limb length by 3-4 years
▰ Rapid foot growth requires frequent shoe
changes in infancy and childhood

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Staheli L. Fundamentals of pediatric orthopedic. 5th ed. Seattle: Wolters Kluwer; 2016. p. 24–32.
 GROWTH OF FOOT IN CHILDREN:
ARCH DEVELOPMENT

▰ Foot longitudinal arch develops with advancing age

▰ Foot flat in the infants foot is due to abundant
subcutaneous fat, less muscle control, and joint laxity
▰ Before 2 years old: 97% have flatfoot
▰ Research findings vary in the timing to significant
changes to the longitudinal arch
▻ Between the ages of 2 – 3 years
▻ Up to pre-school age, or
▻ Up to the age of 10 years

Fritz BB, Mauch M. Foot development in childhood and adolescence. In: Luximon A, editor, Handbook of footwear design and 14
manufacture. Germany: woodhead publishing.
Staheli L. Fundamentals of pediatric orthopedic. 5th ed. Seattle: Wolters Kluwer; 2016. p. 24–32.
 GAIT DEVELOPMENT IN CHILDREN

<3 years old

3-7 years old

> 7 years old

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 GAIT DEVELOPMENT IN CHILDREN

<3 years old

3-7 years old

> 7 years old

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 GAIT DEVELOPMENT IN CHILDREN

<3 years old

3-7 years old

> 7 years old

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Common Foot
Abnormalities in Children

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 COMMON FOOT PROBLEMS IN CHILDREN
PRESENTED TO FAMILY PHYSICIAN

1. Flat feet Foot abnormalities in children vs adults:

2. Heel pain
3. Hallux valgus Children Adults:
4. Toe walker • Developmental • Acquired,
• Arthritis or
• Congenital
5. Clubfoot • Degenerative
6. Poly/syndactyly
7. Curly toes
8. Intoeing
9. Outtoeing
10. Foot deformity
Krul, M., van der Wouden, J. C., Schellevis, F. G., van Suijlekom-Smit, L. W., & Koes, B. W. (2009). Foot problems in children presented to the
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family physician: a comparison between 1987 and 2001. Family Practice, 26(3), 174–179.
1. FLAT FEET

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 FLAT FEET (PES PLANUS)

▰ Loss of the medial longitudinal arch of the foot

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Balasankar, G., & Ameersing, L. (2015). Common Foot and Ankle Disorders in Adults and Children. Research Journal of Textile and Apparel, 19(2), 54–65.
Halabchi F, Mazaheri R, Mirshahi M, et al. Pediatric flexible flatfoot; clinical aspects and algorithmic approach. Iranian journal of pediatrics. 2013 Jun;23(3):247.
FLAT FEET (PES PLANUS)

What to assess:
• Rigid?
• Symptoms?
• Onset?

Flexible flatfoot Rigid flatfoot

• flattened arch during • stiff, flattened arch on Refer to Physical Medicine
and Rehabilitation specialist

weight bearing, and off weightbearing

normal arch during
non weight bearing • most are associated
• may be with underlying
asymptomatic or pathology
symptomatic

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Balasankar, G., & Ameersing, L. (2015). Common Foot and Ankle Disorders in Adults and Children. Research Journal of Textile and Apparel, 19(2), 54–65.
Halabchi F, Mazaheri R, Mirshahi M, et al. Pediatric flexible flatfoot; clinical aspects and algorithmic approach. Iranian journal of pediatrics. 2013 Jun;23(3):247.
2. HEEL PAIN

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 HEEL PAIN IN CHILDREN

▰ One prominent culprit of pediatric heel pain is Sever’s disease, or

calcaneal apophysitis (James Warren Sever, 1912)
▰ Most common in active children between ages 8 and 15 years
▰ Pathophysiology:
▻ Calcaneal inflammation in a physically active growing child
▻ Overuse injury with an insidious onset of pain
▻ Often not related to a traumatic event
▻ Associated with physical activity and weight bearing

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Fares MY. Sever’s Disease of the Pediatric Population: Clinical, Pathologic, and Therapeutic Considerations. Clinical Medicine & Research. 2021; Volume 19, Number 3: 132-137
 HEEL PAIN IN CHILDREN

▰ Diagnosis:
▻ Comprehensive history taking, physical exam, positive
heel squeeze test
▻ Radiographic imaging can help excluding other diagnoses
▰ Treatment options are almost always conservative
▻ The use of ice, activity restriction
▻ Stretching and strengthening exercises
▻ Modalities
▻ Oral and topical (NSAIDs)

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Fares MY. Sever’s Disease of the Pediatric Population: Clinical, Pathologic, and Therapeutic Considerations. Clinical Medicine & Research. 2021; Volume 19, Number 3: 132-137
3. HALLUX VALGUS

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 HALLUX VALGUS (BUNIONS)

▰ Lateral deviation of the great toe at the metatarsophalangeal

(MTP) joint (Hallux-valgus angle>15 degrees)
▰ Predisposing factors:
▻ Positive family history (usually maternal)
▻ Female gender
▻ Pes planus
▻ Relatively long first metatarsal
▻ Constrictive footwear
▻ Musculoskeletal conditions such as rheumatoid arthritis
The risk of a lateral hallux deviation increases up to 30% if
outdoor shoes are two sizes too short

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Harb, Z., Kokkinakis, M., Ismail, H., & Spence, G. (2015). Adolescent hallux valgus: a systematic review of
outcomes following surgery. Journal of Children’s Orthopaedics, 9(2), 105–112.
 HALLUX VALGUS (BUNIONS)

▰ Symptoms: pain, erythematous, clinical deformity, unsatisfactory cosmesis, and

difficulty finding appropriate footwear.
▰ The treatment is controversial
▰ Non-operative management have a limited role in preventing progression:
▻ Footwear modifications
▻ Orthotics and analgesia
▰ Surgical correction is often indicated once conservative treatment has failed
▻ High prevalence of recurrence of deformity after surgery (up to 61%)

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Balasankar, G., & Ameersing, L. (2015). Common Foot and Ankle Disorders in Adults and Children. Research Journal of Textile and Apparel, 19(2), 54–65.
4. TOE WALKER

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 TOE WALKER (JALAN JINJIT)

▰ Toe walking: inability to achieve heel strike in gait

▰ Commonly associated with some medical conditions:
▻ Neurological problems, e.g cerebral palsy, muscular distrophy
▻ Muscular dystrophy
▻ Orthopedic conditions, such as clubfoot
▻ Autistic spectrum disorders
▻ Sensory processing disorders

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CasertaAJ, PaceyV, FaheyMC, GrayK, EngelbertRHH, WilliamsCM. Interventions for idiopathic toe walking.
Cochrane Database of Systematic Reviews 2019, Issue 10. Art. No.: CD012363.
 TOE WALKER (JALAN JINJIT)

▰ Idiopathic toe walking (ITW):

▻ Diagnosis given to healthy children who persist in toe
walking after they should typically have achieved a heel-
toe gait (Engström 2012: 5% of healthy children)
▻ Diagnosis of exclusion: with no signs of a neurological,
orthopedic, or psychological condition
▰ Terminology:
▻ "habitual toe walking" (GriHin 1977)
▻ "idiopathic toe walking" (Conrad 1980)
▰ The population demonstrated Achilles tendon tightness
CasertaAJ, PaceyV, FaheyMC, GrayK, EngelbertRHH, WilliamsCM. Interventions for idiopathic toe walking. 31
Cochrane Database of Systematic Reviews 2019, Issue 10. Art. No.: CD012363.
Engström, P., & Tedroff, K. (2018). Idiopathic Toe-Walking. The Journal of Bone and Joint Surgery, 100(8), 640–647
 TOE WALKER (JALAN JINJIT)

▰ Idiopathic toe-walking
▻ At 10 years, 79% children had spontaneously ceased
toe-walking
▻ Children who still toe-walked at the age of 10 years
demonstrated some neurodevelopmental comorbidity
▰ Treatment:
▻ Stretching exercise to prevent tightness of calf muscles
▻ Insole with heel pad

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Engström, P., & Tedroff, K. (2018). Idiopathic Toe-Walking. The Journal of Bone and Joint Surgery, 100(8), 640–647
5. CLUB FOOT

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 CLUBFOOT (CTEV)

▰ A congenital malformation occurring in the 2nd trimester

▰ Due to an excess of synthesis and accumulation of collagen In the
ligaments, tendons, and muscles
▰ This accumulation of collagen is at its maximum the first year of life and
continues until the 3rd or 4th yearà might be a cause of relapses

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Staheli L. Clubfoot: using ponseti method. Third edition. 2009
 CLUBFOOT (CTEV)

Typical clubfoot Atypical clubfoot

Syndromic clubfoot – such as

Positional clubfoot
arthrogryphosis

Delayed treated clubfoot beyond 6 Neurogenic clubfoot –such as

months of age. spina bifida

Teratologic clubfoot – such as

Recurrent typical clubfoot
congenital tarsal synchondrosis

Alternatively treated typical

Acquired clubfoot – such as
clubfoot includes feet treated by
amniotic band syndrome
surgery or non-Ponseti casting
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Staheli L. Clubfoot: using ponseti method. Third edition. 2009
 CLUBFOOT (CTEV)

▰ Several authors have reported that the Ponseti

method is more effective than other methods
▻ More long term and effective success rate.
▰ Ponseti method:
▻ Manipulation
▻ Casting
▻ Achilles tendon tenotomy
▻ Foot abduction brace
▰ Surgical procedures are recommended if
conservative treatment fails

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Balasankar, G., & Ameersing, L. (2015). Common Foot and Ankle Disorders in Adults and Children. Research Journal of Textile and Apparel, 19(2), 54–65.
Staheli L. Clubfoot: using ponseti method. Third edition. 2009
 FUNCTIONAL PROBLEMS DUE TO FOOT
ABNORMALITIES IN CHILDREN

•Foot joint •Impaired gait

malalignment effectiveness Activity/
Decrease
•Instability •Fatigue, pain participation
Quality of Life
•Muscle •Motor skills restriction
imbalance or problems
overuse

▰ Up to 63% children with flexible flatfeet have functional impairment

▰ Kothari et al 2015: The greater the hindfoot eversion, the worse the QoL
▻ Increased hindfoot eversionà impaired push off à symptoms

Kothari, A., Dixon, P. C., Stebbins, J., Zavatsky, A. B., & Theologis, T. (2015). The relationship between quality of life and foot function in children with flexible flatfeet. Gait & 37
Posture, 41(3), 786–790.
Neumann, Donald A.. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. United Kingdom: Elsevier, 2017.
 FUNCTIONAL PROBLEMS DUE TO FOOT
ABNORMALITIES IN CHILDREN

•Foot joint •Impaired gait

malalignment effectiveness Activity/
Decrease
•Instability •Fatigue, pain participation
Quality of Life
•Muscle •Motor skills restriction
imbalance or problems
overuse

Damayanti et al 2018: Significant difference in the

QoL score in school functioning domain between
children with flatfoot and normal feet <11 years

Lööf E. Additional challenges in children with idiopathic clubfoot: is it

just the foot? J Child Orthop 2019;13: 245-251.
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Damayanti Y,Hadisoemarto PF, Defi IR. Flatfoot decreases school
functioning among children <11 years of age. Univ Med2018;37:50-6
Role of General
Practitioner

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Role of GP Complain of foot problems in
children

Initial
screening

History taking Physical examination

Look, feel, Brief gait

Symptoms Risk factors Special test
move inspection

• Pain
• Stiffness
• Fatigue • Gender
• Motoric • Family history
problems • Footwear Physiological Suspected pathological
• Physical activity
• Medical history
(musculoskeletal,
neurological problems)
Observation Refer
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Physical Examination:

Look, feel, move Brief gait inspection Range of Motion

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 Physical Examination
Foot Posture Index
Special test
Rigid or flexible flat foot examination

Footprint analysis
a)Arch index,
Arch index= B/A+B+C;
b)Chippaux-Smirak index= B/A × 100%
c) Staheli arch index= B/C × 100%
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Management of
Pediatric Flatfoot

Refer to Physical Medicine and

Rehabilitation specialist

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 Role of Physical Medicine & Rehabilitation

▰ Functional assessment ▰ Management

▻ Neuromuscular function ▻ Exercise
▻ Sensory perception function ▻ Footwear Multidiscplinary Approach
▻ Gross motor function ▻ Orthosis
▻ Gait analysis ▻ Assistive device
▻ Muscle strength function ▻ Casting/splinting Team-work
▻ Joint flexibility function ▻ Modalities
▻ Activity of daily living ▻ Pain management

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Summary

▰ Not all foot “abnormalities” in children is pathological

and need particular treatment

▰ GP have an important role to do an initial screening

assessment and make a proper referral

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Thank You

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