Amniotic band syndrome (ABS) is an uncommon, congenital fetal abnormality with multiple disfiguring and disabling manifestations. A wide spectrum of clinical deformities are encountered and range from simple ring constrictions to major head, face and internal organ defects. Lower extremity limb malformations are extremely common and consist of asymmetric digital ring constrictions, distal atrophy, congenital intrauterine amputations, and clubfoot. Although debated, early amnion rupture with subsequent entanglement of fetal parts (mostly limbs and appendages) by amniotic strands is the primary theory of pathogenesis.

Amniotic band syndrome is associated with an excessive number of synonyms and acronyms such as congenital constriction band syndrome, Streeter's dysplasia, Simonart's bands, amniotic band disruption complex, congenital annular defects, congenital ring constrictions, ADAM (Amniotic Deformity, Adhesion, Mutilations) complex, TEARS (The Early Amnion Rupture Spectrum) of defects, and fetal disruption complex. The overabundance of synonyms/acronyms used to describe the congenital malformations in ABS attest partly to the confusion surrounding its etiology.

Current literature supports the theory that early amniotic rupture leads to the formation of fibrous strands that entangle limbs and appendages. This sequence affects the development of the embryo and leads to the findings seen in ABS. Therefore, nearly all cases reach their final form before birth with tissue damage healing before birth. The nature and severity of deformities that result appears to be related to the timing and initiating event of amniotic rupture.

Clinical Findings

Amniotic band syndrome is a complex collection of asymmetric congenital anomalies, in which no two cases are exactly alike. However, several characteristic features are relatively consistent findings. Distal ring constrictions and intrauterine amputations, are the most common findings of ABS and are typically seen in the distal aspect of extremities. Multiple extremity involvement is usually expressed with an average of three extremity parts affected.

Incidence

Amniotic band syndrome is not a rare anomaly as first described more than a century and a half ago and appears to be rising. Once believed to have an incidence of 1:100,000, recent literature supports the incidence today as 1:1200 to 1:1500 births. No distinct sex predilection has been determined. Nearly sixty percent of the cases documented have some sort of abnormal gestation history. Prenatal risk factors associated with amniotic band syndrome include prematurity (<37 weeks), low birth weight (<2500 g), maternal illness (during pregnancy), maternal drug exposure and maternal hemorrhage/trauma. Attempted abortion in the first trimester is also a highly associated finding.

Family history seldom reveals any direct inheritance pattern, since the syndrome occurs in no particular association with know genetic or chromosomal disorders. Karotypes are virtually always normal, and the syndrome is almost always sporadic in nature. Infants of young, black women who have been pregnant more than once (<20 years, more than one pregnancy) show the highest prevalence. incidences of malformations seen in the hand are two times as common as accompanied foot deformities.

Pathogenesis

Many theories concerning the pathogenesis of ABS have been proposed and debated. Furthermore, no single pathogenic conclusion has been determined to reconcile the diverse findings seen in ABS. However, much of the controversy still centers around a fundamental question: Is ABS a primary event of an intrinsic (endogenous) fetal anomaly or a condition extrinsic (exogenous) to the fetus that is secondarily involved?

Although a number of experimental models have been developed to reproduce its occurrence, no unified theory exists. It is easy to believe the amniotic band theory proposed when the majority of pregnancies (60%) demonstrate an abnormal pregnancy history. However, this does not explain the remaining 40% occurrence of ABS in mothers with no abnormal prenatal history. One may never reconcile the differences in findings seen in ABS into a single pathogenic scheme. Perhaps, ABS is composed of a combination of causes as stated above.

Characteristic Features

Amniotic band syndrome is a poorly defined clinical entity, owing partly to its debated causes and large number of different names. However, it is routinely characterized by distinct fetal malformations, which should make its diagnosis unmistakable.

The most common triad of clinical manifestations include congenital distal ring constrictions, intrauterine amputations, and acrosyndactyly. These anomalies appear most frequently in the distal aspect of extremities without other organ involvement. It has been found that ABS is the most common cause of a terminal congenital malformation of a limb.

Additional abnormalities encountered routinely with ABS include webbing of the fingers or toes, progressive lymphedema (swelling), clubfoot, stunted growth of the small bones in the fingers and toes and limb length discrepancy. Less common findings include: pseudarthrosis, metatarsus adductus, peripheral nerve palsy, dystrophic nails, postnatal gangrene, cleft lip and palate, skin-tube pedicles, dislocated hip visceral body wall malformations and eccentric craniofacial synostosis defects. Owing to the fact that no two cases are exactly alike, only some of these above-mentioned defects are present in each individual case. Other congenital brain abnormalities, cardiac malformations, short statue, spina bifida, and added miscellaneous conditions reported in the literature probably represent coincidental findings. Fetal death associated with amniotic band strangulation of the umbilical cord has also been reported.

Amniotic bands are more likely to constrict, entangle or amputate fingers or toes that protrude the furthest. In the hand, digital amputations most commonly involve the index, middle, and ring fingers, whereas in the foot, amputations of the big toe are most often noted. Congenital band indentations are usually at multiple levels with or without distal lymphedema (swelling). However, these fibrous band indentations are noted encircling the fingers or toes of the newborn child most frequently. Bands are of variable width and depth, ranging from shallow indentations of the skin and subcutaneous tissue to deep grooves extending down to deep fascia or bone. Proximal bands occur more commonly in the lower extremity and have been associated with neural compression. Osseous abnormalities occurring at or below band indentation such a bony fusion, angular deformities, and discontinuity have infrequently been reported.

If ring constriction is severe, the veins, arteries, lymphatics, and nerves may be comprised. However, vascular insufficiency is seldom symptomatic. Neurological impairment is usually attributed to axontmesis or neurotmesis. This may be caused by direct pressure from the constriction band or attributable in compartment syndrome distal to the band in infants with rapidly progressive swelling.

Distal digits are typically malformed, owing to phalageal hypoplasia or terminal amputation. Acrosyndactyly (fenestrated syndactyly) is frequently associated with distal amputation. This type of syndactyly involves the binding of adjacent digits in a “lassoed” appearance. If acrosyndactyly is present, it invariably is associated with a proximal interdigital sinus or cleft that communicates from dorsal to plantar. The cutaneious syndactyly seen usually does not involve underlying bony fusion.

A strong relationship between ABS and clubfoot exists. A 31.5% incidence of associated clubfoot deformity and ABS can be correlated with 20% occurring bilaterally. In the majority of cases, the clubfoot deformity present is inordinately rigid and unresponsive to conservative modalities.

Limb length discrepancy has also been noted in legs encircled by amniotic bands with an average functional deficit of greater than 2.5 cm. This often results in biomechanical abnormalities and altered gait patterns.

Diagnosis

Ultrasonographic analysis allows for the detection of ABS prenatally by visualization of amniotic sheets or bands attached to the fetus. In the first trimester, it is extremely difficult to detect ABS, especially if the bands are limited to the extremities. However, in the second and third trimester of pregnancy, it is relatively easy to detect the major anomalies of ABS by its characteristic features and restrictions of motion. When characteristic asymmetric fetal anomalies are observed ultrasonographically, regardless of the presence or absence of fibrous membranes, ABS should be considered.

Although visualization of amniotic bands on ultrasonography is helpful in confirming ABS, it is not in itself a diagnostic feature of the ABS. Recently, amniotic sheets or bands have been described as aberrant sheets of tissue, often amnion and chorion, having a free edge within the amniotic fluid. The free edge does not attach to the fetus and have been labeled “innocent amniotic sheet”. These sheets do not restrict fetal motion nor cause any fetal abnormalities.

Additionally, elevated maternal serum alpha-fetoprotein (MASFP) has been associated with ABS. However, elevated MSAFP is not diagnostic for ABS, since it is also elevated in neural tube defects, placental chorioangioma, and congenital nephrosis. MSAFP is now a standard screening test recommended for all pregnancies, though rarely elevated.

Treatment

Several treatment options are available for the lower extremity manifestations of ABS. Shallow grooves or bands require no operative treatment, unless they interfere with circulation or lymphatic drainage. Deep constriction bands often present with swelling distal to the band, extreme pain, and diminished circulation and must be surgically released immediately to prevent risk of gangrene or auto-amputation. Surgical excision of the fibrous band and any necrotic tissue with circumferential Z-plasty or W-plasty are the procedures most commonly employed. Removal of the constriction band may be accomplished in a one or two stage release, usually beginning at three months of age. Early surgical intervention is necessary to prevent progressive lymphedema. Patients treated late in the course of the syndrome often heal very slowly with secondary eczematous skin changes to distal parts.

When deemed necessary, subcutaneous fat and fascial flaps are advanced into the defect to prevent reoccurrence of the deformity. If edema persists after correction of the band, excision of the edematous area (debulking) may be necessary, with direct closure or conversion of the overlying skin to thick, free partial thickness skin grafts. Gross motor and sensory deficits distal to the bands resulting in neuropathy with secondary ulceration and osteomyelitis (bone infection) are best treated with amputation and fitting of a prosthesis. It is fairly uncommon that the underlying bones to be affected, however, if they are then cresentic osteotomies may be indicated.

Desyndactylizations may also need to be performed in conjunction with skin grafting of hypoplastic bones. Due to the high incidence of associated rigid clubfoot deformity, aggressive surgical correction is often required. Limb length discrepancies greater than 6 cm may require leg-lengthening procedures.

Overall, the goal of pedal care is to create a functional foot and to minimize additional problems as the child grows. Parental counseling is recommended to convey there is no known associated risk for subsequent pregnancies.

Conclusion

Amniotic band syndrome is an uncommon fetal malformation with increasing prevalence. It is a constellation of congenital anomalies that lacks a precise definition and satisfactory pathogenic explanation. Multiple asymmetrical limb, craniofacial, visceral, and body wall defects are commonplace. Although a myriad of fetal deformities can ensue, manifestations in the foot such as distal ring constrictions, intrauterine pedal amputations, acrosyndactyly, and clubfoot are encountered routinely. With the aid of ultrasonography, a prenatal diagnosis of ABS can be made by serial observations demonstrating restriction of fetal movement. Appropriate surgical intervention can eliminate potential limp threatening constrictions and provide a remarkably improved quality of life for these patients.

Deformities of the toes are common in the pediatric population. Generally they are congenital in nature with both or one of the parents having the same or similar condition. Many of these deformities are present at birth and can become worse with time. Rarely do children outgrow these deformities although rare instances of spontaneous resolution of some deformities have been reported.

Malformation of the toes in infancy and early childhood are rarely symptomatic. The complaints of parents are more cosmetic in nature. However, as the child matures these deformities progress from a flexible deformity to a rigid deformity and become progressively symptomatic. Many of these deformities are unresponsive to conservative treatment. Common digital deformities are underlapping toes, overlapping toes, flexed or contracted toes and mallet toes. Quite often a prolonged course of digital splitting and exercises may be recommended but generally with minimal gain. As the deformity becomes more rigid surgery will most likely be required if correction of the deformity is the goal.

Underlapping Toes

Description

Underlapping toes are commonly seen in the adult and pediatric population. The toes most often involved are the fourth and fifth toes. A special form of underlaping toes is called clinodactyly or congenital curly toes. Clinodactyly is fairly common and follows a familial pattern. One or more toes may be involved with toes three, four, and five of both feet being most commonly affected.

The exact cause of the deformity is unclear. A possible etiology is an imbalance in muscle strength of the small muscles of the foot. This is aggravated by a subtle abnormality in the orientation on the joints in the foot just below the ankle joint called the subtalar joint. This results in an abnormal pull of the ligaments in the toes causing them to curl. With weight bearing the deformity is increased and a folding or curling of the toes results in the formation of callus on the outside margin of the end of the toe. Tight fitting shoes can aggravate the condition.

Treatment

The age of the patient, degree of the deformity and symptoms determine treatment. If symptoms are minimal, a wait and see approach is often the best bet. When treatment is indicated the degree of deformity determines the level of correction. When the deformity is flexible in nature a simple release of the tendon in the bottom of the toe will allow for straightening of the toe. If the deformity is rigid in nature then removal of a small portion of the bone in the toe may be necessary. Both of these procedures are common in the adult patient for the correction of hammertoe deformity. If skin contracture is present a derotational skin plasy may be required.

We discussed fitting infants' shoes in the last article, now your child is past the infant stage and into preschool. Children have usually developed their natural gait by this time, and are running and making lateral movements. At this stage children would rather be running than walking. Being more active requires a different type of shoe and different fitting of the shoes. The growth pattern will change, depending on the child, from a steady growth about every three months, to a spurt pattern. The foot may not grow for a period of time and suddenly grow a size or more in a short period of time. Due to the fact every child is different it is impossible to predict this change in growth pattern. The parent should check, or have a shoe fitter check the child's shoes every two or three months.

Most children of this age range are now attending a preschool, daycare, or mother’s day out program. It is natural for the child to desire the popular shoes that the other children are wearing. Unfortunately because all feet are different the most popular shoe may not be the best for your child's feet. The style of children's shoes often follows the style of adult shoes, but fashion and function often do not go together. The requirements of a child's foot are quite different than that of an adult foot, so adult styles on a child's foot may be a poor choice. An example of this would be the clog style shoe that is popular now. A child who is running and climbing cannot keep this type of shoe on during normal daily activities. Another would be the slipon style of athletic shoe that is becoming popular with adults. A slipon shoe for a child must be fit shorter that usual in order to keep the shoe from slipping off of the foot. This means that the shoe must be replaced more often than a traditional lace athletic shoe.

No two feet are alike. Some are narrow, some wide, and they vary in the overall shape. Style and shapes of shoes should match the shape of the foot. Compatibility is very important in fitting the foot. The shoe may be the proper size but the shape of the last is wrong for the foot. For example, a narrow foot would not do as well in a heavy sole, broad toe style. Wider feet would be better suited for this type of shoe. Children wear their shoes differently. Some shoes will look new after three months wear while other will look totally worn out after three weeks. How your child wears his/her shoes should be a consideration when fitting the shoes. For the child that is hard on his/her shoes, a heavier weight shoe will make a difference in how long the shoe will last.

Due to the wide variety of shoe and foot shapes, and due to the fact that right and left feet are different sizes, the perfect fit does not exist. There are some things you should check when fitting the shoes: toe room, width, throat room, heel fit, anklebone clearance, and compatibility of shoe and foot. The following are guidelines you can use when fitting your child's shoes. Remember fitting is an art not a science, it takes practice and experience.

Toe Room: Generally there is one third inch between sizes. Leaving one-third to one-half inch in the toes will allow for a whole size or size and one half of growth room. Be sure that this room is allowed on the larger foot. If the shoe is too long, the break across the vamp (front of the shoe at the ball) will be at an angle instead of straight. The break or bend across the vamp may also be deeper on a shoe that is too long causing irritation across the top of the toes. As the shoe is worn, the toes will have a tendency to turn up.

Width: Shoe width is probably the most important part of fitting a shoe, but is ignored by most parents. Most parents want the shoe to fit with lots of toe room so that it can be worn for a longer period of time. However, if the shoe is not wide enough, then it will be outgrown in width long before the length becomes a factor. Foot growth is not in equal proportions; the toes are one fourth and heel to ball is three fourths of the total growth. If the shoe is too narrow then the foot cannot grow forward in the shoe, and length becomes less important.

You should be able to lift the leather off of the top of the foot by gently squeezing across the ball of the foot. One-sixth to one-quarter of an inch should give the child ample room for forward growth in the shoe. Be sure that the little toe is not cramped or turned under. Narrow feet are much more difficult to fit than wide feet because most manufacturers do not make narrow widths. Guidelines for fitting a narrow foot are the same, but you may have to try many more styles to find one the fits narrow enough for your child's foot. Frustrated parents will ask, "Will it hurt my child’s foot to wear a shoe that is too wide?" The answer depends on the length of time the shoe is going to be worn and how wide it is. The foot will move constantly in a shoe that is too wide. The motion can cause irritations such as calluses and in some cases blisters. Sometimes insoles can be used to take up the extra space in the shoe, but it is difficult to find them in children's sizes.

Throat Room: The throat of the shoe is on the top where the foot meets the shoe. If there is not enough room between the foot and the shoe in the throat, then the foot will not be able to grow forward in the shoe. The tip of the first finger should be able to be inserted between the foot and the shoe in the throat. This will allow ample room for the forward growth of the shoe. Of course different styles of shoes will require different amounts of room. You cannot allow that much room in a slip-on shoe or loafer. If you do, the shoe will slip off as easily as it slips on. A buckle or Mary Jane style has a low cut vamp but you should still allow room on the top where the shoe and foot meet. The strap will allow for some adjustment of heel fit.

Heel Fit: Your mother always told you to make sure the heel doesn't slip when you are trying on new shoes. A little looseness in the heel is not a bad thing. If the heel is too tight however, you will be guaranteed a blister. Constant pressure on the heel will cause the body to build up a fluid to cushion the spot. Excess room will also cause problems, but just a little room will allow for more natural foot movement. Use caution on sling back shoes and clogs. These styles offer no lateral heel control. As the child runs, the heel will slip to the side, increasing the chances of twisting an ankle.

Anklebone: The anklebone on the outside of the foot is lower on some children and can be a problem area. Athletic shoes with padded collars usually take care of this problem. With dress shoes that are harder and stiffer it can be a source of irritation. Check to see that the topline of the shoe comes above the anklebone or well below it. Sometime a felt heel lift will help until the topline softens.

Compatibility: There are many styles of shoes on the market today, and your child will want the one that is the most popular. However, is that the best shoe for his/her foot? A shoe can be the right size but be totally wrong for the foot. Be sure the shape, or last, of the shoe match the shape of the foot. Matching the shoe and foot shape will be more comfortable for the child and the shoe will look and wear better.

Several months ago a mother brought her daughter in with a pair of shoes that had been purchased at a specialty athletic store. Due to the fact that the child was in a school sponsored activity, the shoe was required for the uniform. The child had bunions and the beginning of hammertoes, and the shoes were very painful for her. The mother inquired about adjustment to the shoes that would allow the child to continue with her activity. After several adjustments on the shoes, they were less painful. However they still did not fit, nor were they compatible with the child's foot. Children will wear shoes that are popular or required for an activity whether they fit or not. It is the parent's job to assist the child in making correct choices. If proper fitting is started at an early age, then the foot will grow to its adult shape with few problems. Hopefully incidents like the one above will be avoided.

article written by: Kirk Watson

In thirty years of fitting children's shoes I have seen many changes in the shoe industry. This is especially true in the style of shoes that parents are purchasing for their babies. Hard leather soles and stiff uppers were the rule many years ago. Since that time we have progressed to rubber or PVC soles. Soft leather uppers that conform to the foot and offer greater freedom of movement are now recommended. Narrow, medium and wide widths have since replaced the traditional B,C,D,E,EE. With all the changes in the children's shoe industry one constant remains, no matter what style of shoes you choose for your baby, they need to fit properly.

Foot problems normally found in adults are now being found among children. I have observed this more in the last ten years. In most cases this can be attributed to ill fitting or improper footwear. Often parents don't know how a shoe should fit or what areas of the shoe need to be checked for proper fitting. Hopefully this article will help insure that parents are more aware of how to fit children's shoes.

Shoes are really not required until the child starts to pull up and cruise around objects. You will notice they stand on their toes and try to edge themselves around a table, sofa, or anything else they can hold onto. Toe gripping allows them to balance themselves and learn to take steps.

Babies feet are very soft and pliable with padding surrounding the foot. This is nature's way of protecting the underlying foot structure. This means the foot is thick, with the heel being narrower. Because of the narrower heel and the flexibility of the foot, high tops are generally better to keep the shoe on the foot. This will also allow for the shoe to be fit a little larger than a lower top shoe.

Fitting shoes is not a science, but an art. It takes practice and experience with different types of shoes and feet. Using the following guidelines, you will be better able to fit your child with the proper shoe size.

Measuring

Both feet should be measured in a standing position if possible. Feet are flexible and will expand in length and width with body weight. There are three measurements taken from the standard branock device. They are length, width and arch length. It is very important to understand that the size the foot measures is not necessarily the size shoe that the child will wear. Differences in construction, materials, last (the form the shoe is made on) and sizing systems will determine the actual shoe size. Note any differences in the sizes of the feet and be sure to fit the largest foot.

Length

How much length is necessary for growth? Generally there is one third of an inch between sizes, and one sixth of an inch between half sizes. Allowing one third inch growth translates to one shoe size. This allows two to three months wear for an infant. Keep in mind the growth rate will vary with individual children. Purchasing shoes that are too large is likely to cause tripping of an already unstable walker.

Width

Judging the proper width of a shoe is not as obvious as the length. Since the length and width of a shoe are proportional, the width will increase along with the length. Width increases about one-fourth inch per full size. Many manufacturers only make mediums. Try to find brands that are made in multiple widths. Remember that the foot is three-dimensional. Two of those dimensions are width and thickness. The thicker the foot or higher the instep, the wider the shoe has to be to accommodate the foot. As we discussed earlier, infant's feet are heavily padded and thick by nature's design requiring a wider shoe. Inserting the tip of the first finger between the shoe and foot at the instep is the first gauge of how well the foot is fitting the width of the shoe. If the finger will not fit then the shoe is not wide enough. Room in the throat of the shoe is critical to allow for the forward growth of the foot into the shoe. Since the growth of the foot is three-fourths heel to ball and one fourth toes most infants will outgrow the width of the shoe before they do the length. Parents will often check the length but not width of shoes. Using the thumb and first finger, at the ball of the foot, gently pull the leather in a lifting motion up from the foot. There should be enough room to lift the shoe material off of the foot slightly, but not in excess. Check the inside and outside of the foot for pressure points and cramped toes especially the little toe.

Heel

If you are fitting a high-top walking shoe on your baby, the heel fit is not a major concern. The heel is covered and the shoe will stay on well. On a lower shoe the heel should stay in the shoe with out popping out when the baby walks. Tightness in the heel will cause more problems than if the shoe is a little loose in the heel. A little looseness is permissible, but not a large gap between the heel and the shoe.

Walk Test

If the child is not walking on their own yet, let them pull up on a chair or fitting stool. All checks on the fit of the shoe should be done with the child standing. Feet are not static but dynamic. Standing will allow the foot to expand in the length and width to the normal size it will be when walking. If the child is walking, let them take a few steps and watching their balance. Take note of the break in the shoe. It should be straight across the ball of the foot. A deep break (excess wrinkle) or breaking at an angle would indicate that the shoe is too wide. Breaking forward of the ball of the foot would indicate that the shoe is too long. Check the shoe again after the child has taken a walk in them and the foot has relaxed and set in the shoe.

Other checks

On a low top, shoe material should either cover the outside anklebone or be far enough below the bone so as not to cause irritation. Always check the inside of the shoe before putting your child's shoes on. Nails, tacks, paper, plastic tags are some of the objects I have found in shoes over the years.

Fitting your child now with the proper size and style of shoe will help prevent possible foot problems in years to come. Longer life spans and more active lives mean more wear and tear on the feet. Don't let your child be like many adults that say, "I wish I had worn shoes that fit when I was a child." "My feet would not be in such bad shape now." If are you able find a local merchant that still knows how to fit shoes, then please make use of his knowledge and experience. If not, remember these tips the next time you buy shoes for your baby.

Written by Kirk Watson

A flatfoot deformity is where the arch on the inside border of the foot is more flat than normal. Flatfoot deformities can occur in all age groups, but appear most commonly in children. Some of these children grow up into adults who have feet with normal arches, but many of these children have pain related to their flatfoot deformity throughout their lives. It is very important that children with flatfoot deformity be evaluated by a podiatrist to determine if they need treatment to prevent future pain or deformity in their feet.

When the young child starts to first walk at about the age of 9-15 months of age, the foot has a fat or chubby appearance where there is a less bony architecture apparent in the foot. At this point in the development of the foot, it is very difficult to evaluate whether the child will have future problems with a flatfoot deformity.

At the ages of two and three, the child's foot starts to show more of its characteristic shape since the foot is less fat and the bones are more prominent. If the child has a flatfoot deformity at the ages of two to three, then it is wise to have the foot examined by a foot specialist such as a podiatrist. The reason that it is important to have the feet examined at this age is because the young foot is still largely made of cartilage, with less bone than would be present in the adult foot. Since cartilage is relatively soft, the abnormal forces caused by a flatfoot deformity may cause permanent structural alterations to the bones and joints of the foot that will persist into adulthood.

The flatfoot deformity in children causes a number of changes to the structure of the foot which is easily recognizable by the trained podiatrist. Flatfoot deformity causes the inside arch to be flattened, causes the heel bone to be turned outward, and causes the inside aspect of the foot to appear more bowed outward than normal. Most cases of flatfoot deformity in children are also associated with excessive flexibility in the joints of the foot which is commonly caused by ligamentous laxity.

Since the flatfoot deformity causes some instability of the foot during gait, children with flatfoot deformity may have complaints in the foot such as arch, heel, or ankle pain which is generally associated with increased standing, walking, or running activities. However, since the excessive rolling inward of the arches of the foot also make the leg and knee more turned inwards, children with flatfeet may also complain of pain in the low back, hip, knee, or leg due to the abnormal mechanics of the foot which is created by the flatfoot deformity.

Diagnosis

As mentioned above, the pediatric flatfoot deformity can be diagnosed at a very early age, but is unlikely to be properly diagnosed unless the doctor is a foot specialist, like a podiatrist, and is familiar with the intricacies of the structure and biomechanics of the foot. After speaking with the parent and child, the podiatrist will examine the foot both while the child is not bearing weight but also while the child is standing, walking or running. Often, the family history is also taken since the foot should be examined closely if the child has a close relative who had a painful flatfoot deformity as a child or adult.

During the examination of the child, the podiatrist is looking for abnormal structure or function of the foot and lower extremity, which could lead to either problems during childhood or adulthood. X-rays may be taken of the foot if a significant pathology is noted or suspected. The more severe the flatfoot deformity and the more significant the complaints in the foot or lower extremity, then the more likely the podiatrist will recommend specific treatment for the flatfoot deformity.

Treatment

If the child has a mild flatfoot deformity and no symptoms, then generally no treatment is recommended other than possibly yearly check-ups by the podiatrist. If, however, the child has a moderate to severe flatfoot deformity of has significant symptoms in the foot or lower extremity, then treatment is indicated.

Treatment generally starts with both supportive shoes, such as high tops, and some form of in-shoe insert such as arch padding for the milder cases of flatfoot deformity. More significant cases of flatfoot deformity may require more exacting control of the abnormal motion of the foot such as that offered by functional foot orthotics. Functional foot orthotics limit the abnormal flat arch shape and rolling in of the heel bone during standing, walking and running activities which helps not only improve the appearance and function of the foot, but also greatly reduces the symptoms in the foot or lower extremities. Calf muscle stretching exercises are also commonly prescribed for children with tight calf muscles since the tight calf muscles can worsen the flatfoot deformity with time and make the child's symptoms worse.

If the child has a severe flatfoot deformity and disabling symptoms which does not respond to foot orthotics, shoes and/or stretching, then surgery to correct the flatfoot deformity may be indicated.

These children may be candidates for a 15 minute outpatient procedure to correct the flexible flatfoot deformity which is referred to as hyperpronation. The procedure is called a Subtalar Arthroereisis. It involves the placement of an implant in the space under the ankle joint (sinus tarsi) to prevent only the abnormal motion, but still allowing normal motion. This brief procedure only requires very little recovery time, and is completely reversible, if necessary. Your surgeon can consult you about this exciting, life-changing procedure.

Knee pain in children may be caused by a variety of conditions. Some of these conditions may be rare but can be quite serious in nature. Knee pain in children should be evaluated by your doctor.

Osgood-Schlatter's Disease

A common cause of knee pain in a growing child is injury to a growth plate in the front of the knee. This may be accompanied by swelling in the area. This condition is called Osgood-Schlatter's disease. It occurs most commonly in children between the ages of 10 -14. It is often associated with playing sports and aggressive bicycle riding. It is felt that the condition is primarily caused by an abnormal pull of the tendon that attaches into the painful area from the kneecap. This tendon is called the patellar tendon.

Treatment of Osgood-Schlatter's Disease

Treatment consists of avoiding activities that aggravate the condition such as kneeling or excessive flexion of the knee. Icing the area and anti-inflammatory medications such as Tylenol or Advil may provide temporary relief. Often the abnormal knee function is due to the way the foot functions. In this instance the foot causes the lower leg to rotate slightly inward. This causes the patellar tendon to pull in an abnormal direction where it attaches in front of the knee causing damage to the growth plate in this area. If this is the cause of the problem then treatment might consist of a custom fitted shoe insert called an orthotic. The orthotic corrects the underlying foot condition that is affecting the lower leg and knee. A podiatrist trained in the use of functional orthotics should be able to evaluate the cause of the problem and if it is caused by abnormal foot function adequately treat the condition.

Sever's Disease

The spontaneous development of pain in children generally indicates some form of injury to the growth plate of a growing bone. This can occur without a specific memorable event. When pain occurs in the heel of a child the most likely cause is due to injury of the growth plate in the heel bone. This is called Sever's disease. A condition that may mimic Sever's disease is Achilles tendonitis. Achilles tendonitis is inflammation of the tendon attached to the back of the heel. A tight Achilles tendon may contribute to Seiver's disease by pulling excessively on the growth plate of the heel bone. This condition is most common between the ages of 8 - 15 years of age and boys tend to be affected more than girls. It is frequently seen in the active soccer, football or baseball player. Sport shoes with cleats seem to aggravate the condition. It is believed that the condition is due to an underlying mechanical problem with the way the foot functions.

Treatment

Home treatment consists of calf muscle stretching exercises, heel cushions in the shoes, and/or oral anti-inflammatory medications like Tylenol or Advil. Icing the area may provide some temporary relief. If the condition persists the child should be evaluated by a podiatrist for abnormal foot function. In severe cases a below the knee walking cast may be required. Treatment may require the use of custom-made shoe inserts called orthotics. Orthotics work by correcting foot function and will fit into most normal shoes.

The spontaneous development of pain in children generally indicates some form of injury to the growth plate of a growing bone. This can occur without a specific memorable event. When pain occurs in the ball of a child's foot the most likely cause is injury to the growth plate of one of the long bones behind the toes called metatarsals. The most common bone involved is the metatarsal behind the second toe. When numbering the toes the big toe is the first toe.

This condition is called Freiberg's disease. This disorder is most frequently seen in the adolescent between the ages of 13 - 15 years of age. It is three times as likely to occur in females as compared to males. The pain is a result of a loss of blood flow to the growth plate in the bone.

Diagnosis

The diagnosis of Friebergs disease is made by x-ray evaluation. X-rays will reveal a flattening of the head of the metatarsal bone. Early changes may be very subtle or not apparent. On physical exam there may be swelling in the area that is tender to touch. A useful tool for diagnosing growth plate injuries and stress fracture is to strike a tuning fork and placing the vibrating tuning fork on the area of the suspected site of injury. Pain with vibration may indicate bone or growth plate injury.

Treatment

Treatment consists of reducing pressure under the affected bone. This may consist of anything from using crutches to a custom insole for the shoe called an orthotic. Left untreated the affected bone may not develop properly and permeate damage to the joint behind the affect toe may result in painful arthritis. Once the joint becomes arthritic surgery to place an artificial joint may be required.

Deformities of the toes are common in the pediatric population. Generally they are congenital in nature with both or one of the parents having the same or similar condition. Many of these deformities are present at birth and can become worse with time. Rarely do children outgrow these deformities although rare instances of spontaneous resolution of some deformities have been reported.

Malformation of the toes in infancy and early childhood are rarely symptomatic. The complaints of parents are more cosmetic in nature. However, as the child matures these deformities progress from a flexible deformity to a rigid deformity and become progressively symptomatic. Many of these deformities are unresponsive to conservative treatment. Common digital deformities are underlapping toes, overlapping toes, flexed or contracted toes and mallet toes. Quite often a prolonged course of digital splitting and exercises may be recommended but generally with minimal gain. As the deformity becomes more rigid surgery will most likely be required if correction of the deformity is the goal.

Underlapping Toes

Description

Underlapping toes are commonly seen in the adult and pediatric population. The toes most often involved are the fourth and fifth toes. A special form of underlaping toes is calledclinodactyly or congenital curly toes. Clinodactyly is fairly common and follows a familial pattern. One or more toes may be involved with toes three, four, and five of both feet being most commonly affected.

The exact cause of the deformity is unclear. A possible etiology is an imbalance in muscle strength of the small muscles of the foot. This is aggravated by a subtle abnormality in the orientation on the joints in the foot just below the ankle joint called the subtalar joint. This results in an abnormal pull of the ligaments in the toes causing them to curl. With weight bearing the deformity is increased and a folding or curling of the toes results in the formation of callus on the outside margin of the end of the toe. Tight fitting shoes can aggravate the condition.

Treatment

The age of the patient, degree of the deformity and symptoms determine treatment. If symptoms are minimal, a wait and see approach is often the best bet. When treatment is indicated the degree of deformity determines the level of correction. When the deformity is flexible in nature a simple release of the tendon in the bottom of the toe will allow for straightening of the toe. If the deformity is rigid in nature then removal of a small portion of the bone in the toe may be necessary. Both of these procedures are common in the adult patient for the correction of hammertoe deformity. If skin contracture is present a derotational skin plasy may be required.

 

Overlapping Toes - Overlapping Fifth Toe

Description

This deformity is characterized by one toe lying on top of an adjacent toe. The most common toe involved is the fifth toe. When one of the central toes is involved the second toe is most commonly affected. The etiology of the condition is not well understood. It is though that it may be caused by the position of the fetus in the womb during development. The condition my run in families so there may be a hereditary component to the deformity.

Treatment

Effective conservative treatment depends upon how early the diagnosis is made. In infancy, passive stretching and adhesive tapping is most commonly used. This may require 6 to 12 weeks to accomplish and reoccurrence is not uncommon. Rarely will the deformity correct itself. As the individual matures the deformity becomes fixed. When surgical correction is warranted a skin plasty is required to release the contracture of the skin associated with the deformity. Additionally a tendon release and a release of the soft tissues about the joint at the base of the fifth toe may be required. In severe cases the toe may require the placement of a pin to hold the toe in a straightened position. The pin, which exits the tip of the toe, may be left in place for up to three weeks. During this period of time the patient must curtail their activities significantly and wear either a post-operative type shoe or a removable cast. Excessive movement at the surgical site can result in a less than desirable result. The pin can be easily removed in the doctor's office with minimal discomfort. Following removal of the pin splinting of the toe may be required for an additional two to three weeks.

 

Hammertoes and Mallet Toes

Description

Another common digital deformity is contracture of the toes in the formation of hammertoes and mallet toes. Hammertoes are described in depth in another article. Mallet toes are a result of contracture of the last joint in the toe. In the pediatric population it is often flexible and not painful. Over time the deformity becomes rigid and a callus may form on the skin overlying the joint at the end of the toe. Additionally the toenail may become thickened and deformed form the repetitive jamming of the toe while walking. The deformity usually involves one or two toes, with the second toe most commonly affected. Mallet toes have several etiologies. Longer toes that are forced against a short toe box in the shoe will, over time, develop a contracture of the last joint in the toe causing a mallet toe.

Treatment

Conservative treatment consists of padding and strapping the toes into a corrected position. This treatment may alleviate the symptoms but will not correct the deformity. Diabetic patients often develop ulcerations on the ends of their toes secondary to mallet toe deformity and the pressure that results from the toe jamming into the shoe. When standing, the toe will demonstrate a contracture, with the tip of the toe facing downward into the floor. If the deformity is flexible a simple release of the tendon in the bottom of the toe will allow straightening of the toe. Following the procedure the patient must avoid shoes that cause jamming of the toe or the deformity can reoccur. When the deformity is rigid surgical correction requires the removal of a small section of bone in the last joint of the toe. On occasion fusion of the last two bones in the toe may be necessary. This requires removing the cartilage from the last joint in the toe and pinning the bones together. When the bone heals it forms a single bone and the toe remains in a straightened position. Healing time is dependent upon the procedure selected. If a tendon release is performed the patient my return to a roomy shoe within a week. If the toe is straightened by removing a section of the bone in the toe it make ten days to three weeks for a patient to return to normal shoes. If a fusion is performed to straighten the toe, the patient may not return to normal shoes for 6 to 8 weeks. Time off from work will depend upon the type of shoe gear that must be worn and the level of activity necessary to perform the job. A minimum of three to four days off from work is generally recommended and longer if the job responsibilities can not be modified to accommodate the normal healing time for the surgery.

Knee pain in children may be caused by a variety of conditions. Some of these conditions may be rare but can be quite serious in nature. Knee pain in children should be evaluated by your doctor.

Osgood-Schlatter's Disease

A common cause of knee pain in a growing child is injury to a growth plate in the front of the knee. This may be accompanied by swelling in the area. This condition is called Osgood-Schlatter's disease. It occurs most commonly in children between the ages of 10 -14. It is often associated with playing sports and aggressive bicycle riding. It is felt that the condition is primarily caused by an abnormal pull of the tendon that attaches into the painful area from the kneecap. This tendon is called the patellar tendon.

Treatment of Osgood-Schlatter's Disease

Treatment consists of avoiding activities that aggravate the condition such as kneeling or excessive flexion of the knee. Icing the area and anti-inflammatory medications such as Tylenol or Advil may provide temporary relief. Often the abnormal knee function is due to the way the foot functions. In this instance the foot causes the lower leg to rotate slightly inward. This causes the patellar tendon to pull in an abnormal direction where it attaches in front of the knee causing damage to the growth plate in this area. If this is the cause of the problem then treatment might consist of a custom fitted shoe insert called an orthotic. The orthotic corrects the underlying foot condition that is affecting the lower leg and knee. A podiatrist trained in the use of functional orthotics should be able to evaluate the cause of the problem and if it is caused by abnormal foot function adequately treat the condition.