Brush up on the complex anatomy of the foot and learn which exam findings warrant referral to a specialist. Orthopedic surgeon Coleen Sabatini, MD, MPH, presents a foot primer for pediatricians, covering how to recognize and care for conditions frequently seen in babies, including clubfoot, flatfoot and Sever’s disease.
All right. And we are going to do a whirlwind tour of the child's foot um and hopefully have some good time for questions at the end. I have no financial disclosures relative to the presentation. Um When we talk about the foot, we first want to talk about the exam and I think the most important thing about the foot is to understand that it is actually a phenomenally complex structure and if it confuses you and if all the conditions of the foot confuse you, then just know that you are not alone in the world. Um and particularly in the world of pediatrics, where the foot is very different at different stages of growth and development and the conditions of the foot can change over time that you as a pediatrician need to be aware of. So I'm going to try today to put into sort of context the various things that can go wrong in a child's foot um at sort of different stages in life, um and hopefully this will be informative for you. So the first thing is always just to talk about exam and again that differs depending on age and functional ability. Whenever you're talking about the foot, you of course need to look at the gate. And so if the child is of walking age, making sure that you watch them walk and what the foot is doing as it moves through. Space is really important. We of course want to inspect the foot and looking at the skins in the folds of the foot and the overall resting position is important, which we'll talk about in a second and then range of motion. A foot, particularly in a young child should be very supple and it should go up and down side to side and all around very easily. And if the foot is very stiff um that right there is a red flag that there's something going on. And so it's very easy to just check up down side side all around. Um and make sure that things are moving normally. Obviously vascular exam, anytime you're talking about a limb is important. And then in a child who is presenting with pain, particularly in a child young enough that they know that there's pain, but they can't localize that pain. Doing an anatomically sound pal patient exam is really important to help localize that pain. So we see kids all the time that have foot pain, but you know, is that tenderness over the navicular tenderness over the fifth metatarsal. And so understanding the anatomy of the foot and doing that exam thoroughly to find the area of pain is really important. Um So if we're going to look at the foot, then this is just sort of a quick note on looking. So you want to look from the side and you want to see is that foot sitting in Dorsey flexion? Is that foot sitting in plantar flexion or is that foot sitting in neutral? And this is particularly were particularly talking about the newborn exam right now. Um And because if if it's Dorsey flexed, plantar flexed, those are not normal. And so if you have a foot that's sitting Dorsey flexed, then that can suggest possibly a cacophony of august foot or a congenital vertical tallis. It's very plantar flexed, particularly folded in. It could be a club foot and if it's neutral. Yeah, that's what it's supposed to be. Um You want to look from the bottom of the foot like this person, the picture here is showing you. Um And if it's curving inward, if it looks like a little kidney bean and it's it's curving in, then that is meta tarsus add duct. This if it's sort of straight but out then that could be cal Canio vargas and again it could be neutral, which is what we like to see. And then we do like to look at the foot from the back and so looking to see if the hell is turned in or turned out is important. Again, that's a little harder on the newborn, much more valuable as the child is becoming a standard. But those are the ways that we will always look at the foot. So you want to look from the side, you want to look from the bottom and you want to look from the back. Um and that will tell you what you're dealing with. So some of you at this point might be like, look this is just a foot. Uh So what could possibly go wrong? Um I love if we could like start everybody throwing out their possibilities but um since we can't really have an interactive moment, um just to note that you could probably generate 2025 different diagnoses right now on things that could go wrong in a foot um in the child, If we think just about the newborn we can see metatarsals abduct us cal kenya, valdas, foot, club, foot, congenital, vertical tailless, polly, directly Cindy, actually macro directly ola. Good. Actually, you can have an absence of the foot or part of the foot. Like we would see in an amniotic band and a lot of other things. So again, if if the foot is sort of an enigma to you, it's because there's so many different things that could be happening. Um When again, just to note that in examining the newborn foot, it is actually a really small and complex structure. Um Physical exam though alone is usually all you need to determine if there's a problem in what that problem could be. Um And I say that only so that you know that X rays are really not helpful in a newborn unless you know specifically what you're looking for and you know that thing is helpful to get an X ray on and therefore you order a very specific X ray. So I would say that if you have a child who has a sort of an abnormal foot and you're not really sure what's happening um that's probably just want to refer in. I wouldn't bother doing the dose of radiation to the foot because many things we don't get X rays on until they're at least a year of age or older, we can learn most of what we need to from the physical examination. So, um, I just, I'm going to pause for a second and let you look at this and think to yourself what your diagnosis is for this foot. And hopefully everybody noted that the foot itself actually looks quite normal. It's like a normal looking foot, but it's very excessively Dorsey flexed at the ankle. Um and so foot looks normal, ankle significant dorsal flexion, so much that the top of the foot can actually touch the tibia. And this is a newborn. So, we're starting with some newborn problems here, and this is a Falconio valdas foot. So, um, this is one that can make new parents very bothered when the baby first comes out and they see the foot sort of grossly deformed up against the tibia. And so this is a Dorsey flexed reverted foot. The top of the foot often does touch the tibia. The foot can be diverted in the heels and values which has the name kilkenny. Oh, vargas! And if you try to bring it down, it's actually very difficult. You can often get it to neutral, but you can't really plantar flex it more than that because the foot has been there the entire time the baby was developing. So those dorsal structures are very tight and we tend to think of Falconio valdas foot as a packaging problems. So this does tend to happen more and uh first born Children um and is associated with other packaging problems um which we'll talk about in one second, the treatment for a Falconio valdas foot, even though it looks very, not normal and it's very, can be very distressing those first few weeks, it's reassurance. Um If the family feels like they have to do something and you feel like you need to give them something to do. Then gentle stretching can be valuable again because those dorsal structures are tight and the foot is up and out, then you would encourage them to stretch it down and in just to stretch the structures that were tight. Um and then reassurance. So reassurance, maybe a little gentle stretching if they feel like they have to do something and then a lot more reassurance. Uh Most of these will improve even if they do nothing. The family being they, they're so the family does nothing, it will still get better on its own, usually actually within just the first six weeks or so, but pretty much all of these completely resolved by about nine months of age. Honestly, the reason to re to refer these is if you need reassurance that you're not missing something. Um and if you're not 100% sure that the foot itself looks normal. Again, in a Kakenya values foot, the foot should be normal looking. Um it's really the deformity is more at the ankle area. Um But I would say that um you don't so you don't need to refer these and you don't really need to worry, but you do need to get a screening hip ultrasound on these Children. Um And that would be at six weeks, just like you would do for a breech baby because again, this is a packaging problem and there is an association between cal kenya valdas foot and developmental dysplasia of the hip. All right, So then you're going to pause for a moment and look at those feet and you're gonna tell me or you're going to tell yourself what this is. And you probably thought of two possibilities. Here. one is club foot and one is meta tarsus abduct us. And you would tell me that you can't tell which one is which without actually feeling the foot. And you would tell me that the way that you would tell the difference between metatarsals abductors and club foot is whether or not the achilles tendon is tight, because in club foot the achilles tendon is tight, but in metatarsals abduct us, it is not. So let's talk about those things. So club foot is incredibly important to know about and understand it is a structural deformity of the foot um in which the forefoot is in caves and add duct this and the hind foot is embarrassed and a quaintness. And so if we were in a room together, I would have you act this out with your hands. So if everybody can put their hand on the table or on some flat surface and you're going to create an arch in your hand which is K. Avis. So okay, this is a high arch add duct. This is where the foot curls in. So that would be this little bean shape of your foot. Various is the hind foot. Um And so the various brings the hell in and a queen, this is the achilles tendon being tight. And so that would do that. Um And that's how you get this little club foot. Um And so the child is born basically with the bottom of their foot facing upward. Um So que vous abductees various and a quietness are the four parts that you see in a club foot. Um And so the adductor, this is metatarsals abductees. Which is why it can be hard to distinguish between those two, but in metatarsal seductress, the achilles tendon is not tight and the foot can be brought above neutral, but in club foot it cannot. Um Club foot is super important because one, it absolutely requires treatment and two, it's incredibly common. So about 1 to 3 out of 1000 live births globally are due to our club foot. So it's the most common congenital musculoskeletal anomaly that we see Um in certain populations, it's even higher, so um Polynesian ancestry. So uh we see as many as 7-8 out of 1000 live births, it is more common in male than female. And it can be associated with a positive family history or a maternal history of smoking in the first trimester. But the vast majority of kids are have no family history and certainly did not have a smoking history, um, exposure history and um, so they're just spontaneous genetic mutations that cause this club foot deformity. Really. We think of bilateral cases about 50%. In unilateral cases, about 50 the vast majority are idiopathic, but there can be some associated um uh conditions as well. So those are important to to think about if the child does have an abnormal foot. But again, the vast majority of club foot is idiopathic and there's nothing else wrong with the child. Um and there's no cause for it other than the spontaneous mutation. So again, this is just showing you the four parts of the club foot deformity, which is the cave is the abductors, the various and the acquaintance. Um I don't expect, I'm not going to go over this and I don't expect anybody to really read this. But this is the path of anatomy of club foot. These are all of the things that are going wrong in the foot that makes, so this is what makes it different from a regular foot. And you can see that there are all sorts of bony um al alignment problems and all sorts of soft tissue problems. Um And so historically this was treated with very significant surgery starting at about six months of age. Um And thankfully through the work of a man called Ignacio pon city, we now do very little surgery for these Children. And instead we use a casting technique. Uh but there's a lot of things that we need to fix in a club foot. So again, the most important finding is that the heel court is tight. Uh And that's how you're going to distinguish between metatarsals abduct us and club foot. And again, a club foot often looks just much more severe than a metatarsal seductress. But if ever you're not sure, then please just refer. It's better to refer a meta tarsus abduct us unnecessarily and we just get to reassure the family and you and ourselves. Um It's better to do that than to not refer a club foot that needs treatment um severity to really varies in club foot but mild to the severe. No matter how bad the club foot is, we will still always try the technique that I'm going to describe to you here, which is the ponte city method. We do try to start treatment as early as possible so we will happily start a child and cast within the first few days of life, basically a lot of the kids now we're meeting in utero. Um So we're doing fetal medicine, consults with the families. Um And then there's some that um you know either it wasn't caught on the ultrasound or it was caught but the family wasn't referred in for a fetal medicine appointment. That appointment is not critical. Um But it is just nice to be able to tell the family what to expect and to allay their anxiety and fears around this. So I feel I feel like it's sort of a social support visit more than more than an actual medical necessity. Uh And then we do like to see the Children, like I said usually within the first 1 to 2 weeks of life if the child's having any latching problems or any concerns, feeding wise, I'll usually hold off for another week or two. But for the most part kids are doing really well, so we'll start casting right away. Um They do come every week for casting. Um And you'll see that we can take a foot that looks quite deformed and as we go through a series of foot manipulations in casting and we can completely transform the position of the foot. Again, we're not doing anything else in this sequence of pictures other than doing these casts. So we'll put the cast on, they come back a week later, we'll put a new cast on and we take the foot Through this whole series of corrections on average, it takes 5-8 weeks of casting to get to the point where we're done with this phase of casting. And then over 90% of Children Have after after the conclusion of of casting where we've got it as much corrected as possible, they still have a very tight achilles. So over 90% of Children and most practices now it's 95-99% of Children um will then undergo a hell courts anatomy. This particular one is, I'm showing you in an operating room. But if the child is actually quite calm child and does well with casting doesn't kick or cry a lot will actually do there. He'll courts anatomies awake. Um and not have to give general anesthesia And for the older kids or the more robust active ones, then we will do anesthesia. And so it's a very small incision on the back of the ankle just medial to the achilles tendon. And we do release the achilles fully. It's a full tin. Ah to me, so cutting of the tendon that allows release of the achilles in the foot fully corrects upwards and then we'll cast in maximum Dorsey flexion. And in the three weeks that that last cast is on the achilles tendon will grow back fully and it's nice new lengthened position. All right. Um After that is actually when the work for the parents really start. So it is hard to come every week and have to do a cast change and have to come to clinic but passively then the rest of the week all they have to do is make sure the cast is staying on okay and that they're keeping it clean. Once the cast comes off we enter into the foot abduction brace faced because the club foot is not just a foot deformity. It's a whole lower leg problem where the muscles are not normal compared to the other side. Or if it's bilateral they're just not normal compared to normal. Um So the muscles are are abnormal. Some of some kids actually have even like smaller nerves on a club foot side. And so there's just abnormal signal to the foot and the foot very much wants to pull back in. And so bracing is critical to maintain the correction that we've obtained through those weeks of casting and the heel court sonata me. Um Previously we would sort of across the board in ponts et treatment. We would do three months full time of the abduction brace and then three years at nighttime. And now we've got more aggressive because we saw that there's a lot more recurrence. Um And so now it's very surgeon independent in my practice, I have them wear the brace full time until they start to pull to stand. So it's off for about an hour day for bathing. Um And then once they start to pull the stands and they go to just naptime and nighttime brace where up to four years of age. Um That's one of my little patients in Uganda and the little brace that we use in Uganda. There's a ton of different races that have come out over the years. Um And so this bottom corner though is the one that you probably most typically see, which are these little suede leather Mitchell shoes and then this is a standard bar. And then now we have this bar which actually articulates that allows movement. So if you have a patient with club foot in your practice, you might see that we have a straight bar for the first few months and once they get more active and they're starting to crawl around, we'll use this articulated bar so their feet can continue being in treatment but they can also crawl around and be more active, which makes everybody happier. Um So again the shoes in the bar at all times early on and then nap times and all night overnight. Um The number one risk of um of recurrence is families not being adherent to the bracing protocol, the way that they should. So noncompliance is our number one risk factor. And please note that wearing the brace has never been shown to cause any delays in the child's development. Maybe they might walk about one month later than non club foot Children. Um but that hasn't actually fully played out in the literature. And so um please don't tell the families to stop wearing the braces. Um when we're trying to tell them to wear the braces and we've, we've had that issue before. There's definitely not a delay in development from wearing these and there is absolutely a high risk of recurrence. So about 50% of kids We'll need some intervention as they get older, whether that be around if casting or even some additional surgery. And that surgical risk is about 10-40% of kids. Some kids, it's actually a surgery to repair the club foot deformity that comes back other kids. The more common thing is that as they're getting a little older, the imbalance between the weaker perennials that we see in a club foot and the stronger tibial is interior leads their foot to super Nate when they are walking. So they walk, they land on the side of their foot. Um and the foot can become worsening in deformity over time. So we actually do a pretty common surgery where we pick up, pick up the Tibbles interior and move it to the from the medial side of the foot to the center of the foot. And that corrects uh super nated Dorsey flexed foot to a nice neutral Dorsey flexed foot. Um And so things just to know when you have a club foot child in your practice that if the child has a unilateral club foot, um one, it will be more noticeable because you'll have the normal side to compare to. And you'll see that the calf muscles on that club foot side are usually smaller, like the calf is skinnier than the other side. Um, and that leg can actually be shorter. And in about 15% of unilateral club foot Children, the leg is short enough that we might actually recommend um, in equalization surgery for that. Um, and that club for treatment is not always easy. There are some mild and moderate cases which correct very easily and do great, like even if the parents are non compliant with the brace, maybe they'll do fine. But there's other kids that are more severe and have a more relentless desire to recur and so it can actually be difficult with some kids with comfort. So we don't want to set up an unrealistic expectation for the families. And again, it might not be totally fine. Not every person with club foot becomes Mia Hamm and Kristi Yamaguchi and Charles Woodson, who are famous athletes who apparently had club foot. There's some kids with club foot that are severe enough, that we're really just happy that the foot is like walkable. And again, other kids with a more mild form that just do fantastic and you'll never know that they had club foot once they're, you know, 345 running around to live in their life. Again, the bar does not slow down development and recurrence can be a big deal and require additional casting revision to not a me and other surgical procedures. So we've contrasted then club foot. Now, let's talk about metatarsal abduct us, metatarsals abductees differs from club foot because club foot is not a packaging problem, but metatarsals, seductress, we think is that just the feet were curled in underneath the baby while it was developing. And then as after the baby's born, the feet actually will improve on their own over time. Club foot will not do that. And again the biggest distinction that you can find on physical exam between these two conditions is the heel cord being tight. So in metatarsals abductees, achilles is not tight, metatarsal doctors is a relatively common condition. You do see this inward deviation of the forefoot relative to the hind foot. Um And uh it's controversial whether or not this is related to D. D. H. And torta collis, but in general um there's enough evidence that this is a packaging problem and therefore associated with those conditions that I do get for severe metatarsals abduct us or moderate metatarsals abductees. I would do a screening ultrasound at six weeks and those are the two ft conditions that I do screening ultrasounds for metatarsals abduct us in kilkenny of august foot will review that at the end. So um with metatarsals abductees, as you can see here on this little schematic, this is called the hell by sector line. Where you basically cup the hell in your hands, you'll put a visualize it lines centered in those and then you extend the line distillate to the toes. And in a normal foot um the if you bisect the hell with a line and extend it, it will go through the second toe more or less. But if the foot is abducted in your bisecting the hell, it will go through the more lateral toes, as you can see in the schematic. So in the picture here, we're looking at the bottom of the child's foot, we would cut that. He'll draw our line. And you would see here that this is actually a relatively moderate to severe metatarsals abduct us because it's going up the fourth toe. And again, that's the hell by sector line. This is actually great for you. If you have a child in your practice, a newborn who does have metatarsal seductress, um without a tight heel cord, because if it was a tight heel court, you would refer it. But if you're just following metatarsals, abductee issue would do your heel by sector line. Maybe when you first meet the baby, it's up the fourth and then a few months later they come back and it's up the third and then a few months later they come back and it's up to second. Each one of those visits, you're able to reassure yourself and the parents that in fact it is getting better. Just the way we think that it would be all right. So usually the spontaneously correct often within the first six months. Again, this is one of those things that if the parents want to stretch it, they can if it makes them feel better, very few, usually only around 5% might actually need intervention and we'll talk about that in this slide. So if it is flexible, you don't need to do anything, observe and educate the parents that everything is okay, which is the majority of the cases. If it's a very stiff metatarsals abduct us and you can't get it to correct um And it's not getting better than if they're a young child, we would cast them just to do some stretching. And if they're an older child then potentially we would need to cut some bones in their foot where we would cut the cuneiform on the medial side of the foot and lengthen it. And sometimes cut the Q. Boyd on the lateral side of the foot and shorten it. And it would take your little bean shaped foot into a nice normal shaped foot. That is very rare. So again, vast majority of metatarsals abducted is flexible. It will get better on its own after the child is out of the uterus. Um And only if it's rigid or not getting better over the first few years of the child's life. Would you need to refer them? All right. Everybody think about what this might be um In the interest of time, I won't give you much time. This is a congenital vertical tail. Is this is a classic rocker bottom foot where you see a Dorsey flexion of the foot. But you also see this um tightness in the hind foot. And so the I'll show you this schematic of the bones in a second, but it's really a rocker position of the foot bones. So congenital vertical tail list is rare unlike club foot, which is, you know, 1 to 8 out of 1000 live births. CBT is about one out of 10,000 live births. Um The day vehicular is Dorsey dislocated off the tailless and the tail is is truly going in a vertical position. It does cause a flatfoot deformity that's rigid. And so these are these are little kids who have rigid flat foot deformities if it gets missed when they're a baby. Um Unlike club foot, which is much more commonly idiopathic congenital vertical, tell us about 50% of the time is associated with other conditions of a neuro muscular nature. Like arthur hypothesis, spina bifida or tethered court. This is what it looks like. Radiographic lee. And you could just see that the tailless literally is going up straight up as opposed to being horizontal, like it should be. And we do a special view where we Dorsey, sorry, we plantar flex down the foot and if it was a flexible problem called an oblique tailless, then the taylors would line up with the four ft. But you can see here that it remains rigidly vertical. And so this would require treatment. Again, the clinical features are just contraction of a whole lot of soft tissues that you don't necessarily need to know. But there's a lot happening. And this is another example. And again this differs from like a cal Kania valdas foot. Remember because the cal Kania valdas foot was a normal looking foot, just Dorsey flexing the ankle. And you can see here that the foot is going up but it's going up through the mid foot, not up through the ankle. And so this is a classic sort of rocker bottom appearance. And again this is what's happening with the bones where the tail is is really pointed down. It's important to know that this does not have a non operative treatment. Option. Treatment is absolutely necessary for these Children. Um and we usually start that about 3-12 months of age, often off. Honestly, we often started even later than that because it gets missed before that. Um So whatever age they come to us, we will treat um We often do casting opposite of club foot. So in club foot we're bringing the foot up and out and in congenital vertical tail is we're bringing it down and in to stretch all the dorsal structures. We do a series of casts and then we do surgery. In some cases this surgery can be very small, which is just to open up the joint and reduce the two bones and pin them. In other cases it's a very extensive release and it just depends on how severe the congenital vertical Talese's. And these kids, like in club foot also have postoperative bracing with a slightly different protocol, which is not worth your time of me going through because this is rather rare. So let's talk about flat feet. Um So my teaching on flat feet is just because it's flat, it doesn't mean it's bad. Um So flat feet very common but cause a lot of emotional distress, particularly in parents who themselves had flat feet even though they're flat feet never bothered them. Um Remember the Children may not develop an arch until six months to six years of life. So it's very common to have a young patient with a flat foot. Um And if it doesn't hurt we don't want to make it hurt. Uh So we'll talk about that in a second. So flat feet are actually a normal human uh an atomic variant because it is present in 20% of the us population and probably even a bigger percentage of the world's population. Um And so flat feet are actually a normal thing. Um What you want to do if you're examining a patient who has flatfoot is just check for generalized ligament laxity because if they if their foot is flat from because their ligaments are loose than potentially other things are too. Um And then you really want to rule out congenital vertical tail, iStar cell coalition and tight achilles. And remember that in a normal foot, the ankle should be able to Dorsey flex 30 degrees up and it should be able to plantar flex at least 40 degrees down if you can't flex them up and their achilles tendon is tight and if you can't bring them down, that suggests possibly a congenital vertical tail us. So that's why you check those things. Um and uh so this is what it should look like when they're standing. So when you're, when a flat footed person who's got a flexible flatfoot stands, you can see that they have no arch of their foot, They've totally lost it when they stood up. Now if you have them sit back down and look at their foot, they will probably have an arch. So when their non weight bearing, they have an arch, they stand up, they lose their arch. And pretty much every human when they stand, their hind foot is in a little bit of val Ghous, meaning that the hell is going outward when they go up onto their toes, in a flexible flatfoot, which is a normal flatfoot, you will see reconstitution of the arch like you see there, and then the hind foot will move from its slightly out position to its slightly in position. So that's called hind foot valdas into hind foot various. And then they get er Cherie constitution when they go up on their toasts. And that is how you check for whether or not it's a flexible flat foot. So here's a here's a child with a very flat arch as you can see um and then they go up onto their toes and you can see that they have nice archery constitution. Okay, and just by way of comparison, here's a child with a rigid flat foot and you see when they go up on their toes, that their their heel bone is still going out, it hasn't come in and they have absolutely no arch. So that's the difference between a flexible flatfoot and a non flexible or what's called a rigid flatfoot. Okay, so the flexible is normal. The not flexible is abnormal and would need to be referred in um for evaluation. So here's our algorithm. So if we're flexible and the heel cord is not tight. So when you, when you flex up that ankle through the achilles tendon, uh if they can't get at least 10 degrees of Dorsey flexion above neutral, then that's a tight achilles. If the achilles is flexible, then that's a normal flexible flatfoot with without a tight heel cord. And all we're going to do is observe and you're live your life and no intervention is necessary. If the achilles tendon is tight, then we do some achilles stretching and continue to monitor that child. If the flexible flat foot with a tight heel cord gets pain and doesn't get better with stretching than we would consider an operation to address the tight achilles tendon. And if they are rigid flatfoot, which is a small minority of people with flatfoot, then we would consider something like a torso coalition or vertical tallis and then potentially operate if they're symptomatic. These are just examples of achilles tendon stretching. We have an epidemic of tight achilles. So if you have kids in your practice with Seaver's disease, if you have kids in your practice who have painful flexible flat feet, then these are stretches that they should do. I personally like the two bigger pictured stretches. So standing on the stair, dropping that heel down and stretching the achilles tendon or doing this squat stretch where the hell stay on the ground. Um and they get a good stretch, the other 21 of course requires somebody to stretch your achilles for you. Which is a nice lazy way to do your achilles stretching and is fine and little tiny kids but really should not be dependent upon for the older kids. And then the one in the middle there um I find is not very reliable because your pelvis has to be in just the right position and whatnot. So these two here are the ones that I find kids do better with and those are the ones that I recommend to all my patients and do myself. So let's talk quickly about rigid flatfoot and what's happening in a rigid flat foot. So that can be the presence of a coalition. And so coalitions are failures of segmentation so they are present from the time that the you know the foot is developing but often not symptomatic until about age 10. And the reason why they become symptomatic because in a child, as we know most of the foot bones are actually very cartilaginous for the first several years And they only get near their adult level of ossification by about age 10. And so there's always some flexibility through cartilage, but once it becomes bone it's much less flexible. And so these kids develop sort of the rigidity of the of the foot from that coalition as it turns from cartilage into bone. And so that's usually about the beginning of the of the second decade. Um The most common one is a Falconio navicular coalition which you see here. So the cal cane ius is connected to the navicular. Usually there's like a big space here on an X ray. But in a coalition you can see that the two bones are basically fused to each other. It hasn't completely fused, which is why you can still see the line. But this was a if this was just a little bit more mature than it would probably fuse completely. The other more common one is a tell tale locale Caneel coalition. Those are the ones that cause a lot of sub taylor motion problems. These kids can come in with a painful flatfoot. They can have limited sub taylor motion either like clinically they're describing that they they have some difficulty with balancing themselves and their foot in space or on your exam. You might notice is that And then some very severe ones can actually have a spastic perennial flatfoot. But for the most part, they just come in with, you know after age 10 with a painful flatfoot that is rigid on exam. And again, a rigid flatfoot is different than a flexible flatfoot. Um there are however tons of people who have coalitions and don't even know it and live a perfectly normal, fabulous life. We actually don't know what the denominator is, but it's been estimated that as many as 5-5-10% of people have coalitions and only a small number of them become symptomatic. So just because you have a coalition doesn't mean you get surgery. Um and it's thought to just be microfractures through the connection that's causing the pain. If you do have a child that you are concerned might have a coalition because they have a rigid flat foot and it's painful and we want to take a look at it. If you're going to order X rays, please always get weight bearing x rays. Um ap and lateral and then an oblique X ray, which is this because that beautifully shows the volcano Navicular coalition. A real quick note on Sievers disease. So, Sievers disease is one of the UPA facilities that happened in the, in the growing child's skeleton. The most common one of course is Osgood Slaughters at the knee. But Sievers is the cal cannula prosthesis here. Common cause of heel pain often overuse related to our athletes, really get this and its attraction apophis itis um due to repetitive micro trauma through that area. So the achilles tendon comes down and connects to that. And then when they're running and doing a lot of activity, it pulls through that apophis prosthesis and can cause inflammation. Um in kids where it's, you know, just a little bit of symptoms. Usually it's because their achilles tendon is a little bit tight. So get them to do achilles stretches. If they're having a like a limp and um and a lot of pain then they absolutely need to get shut down. They need to rest, they need to ice, they can take some anti inflammatories, work on their achilles flexibility and then they can slowly transition back. Um This is just to note that the best way to find this on clinical exam is that one. They should point to that area of the balconies as their source of pain. They should. This happens usually and kids who are old enough to be able to identify where their pain is. And then if you squeeze with your hand over the cal cannula prosthesis, they should be tender if it's seaver's disease. Um And again, the achilles Mayor may not be tight, but if it is then absolutely, we need to work on some achilles stretching, imaging is usually not necessary here. You would know that they're young enough to have an open cal cane ius apotheosis there and an MRI is very much not necessary. Um We would only do an MRI if we thought they had Seaver's did the appropriate protocol for caesar. Seaver's tried to get them back to sport and it didn't work, then we would potentially be worried about something else. And then the treatment is absolutely symptomatic treatment, non operative management and there's no role for um surgery and Seaver's disease. Uh So if you guys have any questions about that, you can let me know. This is where I would ask you if you know what this is. Um and in the interest of time, I will simply point out that the Navicular is abnormal here. And this is a vascular necrosis of the Navicular, otherwise known as koehler's disease. Very uncommon. Often if it is found, it's in boys more than girls, it can be an incidental findings. So actually we see more colors disease because they broke their pinky toe and their X ray showed this um than actual symptomatic colors. But if you do have a child with mid foot pain in that 4 to 7 year range and they're sort of limping and trying to avoid walking on their mid foot and it's been going on for a while and X ray can be helpful to see if there's coolers and it's usually self limiting. We would treat it with rest sometimes with walking boot and or a cast if it's bad enough that they're really symptomatic. Um and then usually it just gets better on its own and there's not a role for surgery. And the Navicular often, well, sort of real Aasif i over time. Um here you have a patient who presents with medial sided foot pain right over there. Navicular and you see that they have some medial prominence is more than you would expect. And possibly an area of extra navicular. And you get a you know, a bleak view and you see in fact that this patient has an accessory navicular And these are very common. 12% of the population can have them. The majority are asymptomatic. The tighter the shoes, the more symptomatic they'll be um you get this enlargement of the navicular bone, it is autism, a dominant in its inheritance. And again it often gets worse at about the age that bone turns to the ossified bone happens. So around the age of 13. Um And again it's medial arch pain and it can cause pain and swelling. Um surgery for this is possible, but we often try not to do. Surgery will do various asymptomatic rest, stretching, uh physical therapy as needed. But if they have persistent pain in that area, then surgery is a possibility. We just have to be careful with the posterior tibial tendon which inserts at that area. Because if we take out the navicular and then the posterior tibial tendon is left loose, they can have even bigger problems than their accessory navicular. Um So x rays, as we've said, the external oblique is very important, the non operative options or the activity restrictions and honestly wearing a shoe that fits better. Um And then only if they're asymptomatic and nearing skeletal maturity would we operate? Um A real quick note on cable. Various foot. Uh This is a cable. Various foot basically is a high arched foot. Um And a child with a high arch and particularly their toes are then also cocked up is very concerning. So a high arched foot um it should raise a red flag in your, in your mind because these are often about 75% of the time associated with neurologic problem. And those can be a wide range of things that can be cp very common in spina bifida. The low level spina bifida is to have these caves feet, but most importantly it could be shark, oh Marie tooth um which is hereditary, motor and sensory neuropathy, which the most common thing is this cave is foot. And and we need to know about those. So um if you have bilateral cable there's feet, the most common cause of that is Charcot Marie tooth. If you have unilateral cave ovaries, foot, then it's usually a tethered cord or some other spinal dystrophy is um uh and so high arched feet should raise concern and are worthy of evaluation. Um These kids often will have pain during weight bearing because the tripod of the foot is not loading correctly. They can get recurrent ankle sprains, their toes can become Claude and that's certainly as you all know, a very important thing. Um and they can have problems. Often times they come because they're having different, like they're getting paint on the top of their foot because their foot is like rubbing too much on the door some of the shoe because it doesn't fit right. Um So an exam is really important, particularly neurologic exam, looking for dis racism, looking for abnormal reflexes. Um And then we would do, you know, for cable there's foot. We would do a variety of diagnostic imaging. And then the decision making from our part is one, we would always refer to genetics and neurology for these kids if we find them to have cable, there's foot because we want to make sure they don't have charcoal Marie tooth and we'll ask questions to find out and make sure they don't have Friedrich's ataxia because that's another thing. Um and so we're going to look at all of these things, the deformity of the foot, how flexible it is, what their muscle strength is or if they're having weakness or not, we take into consideration there a skeletal maturity and try to identify the underlying disease. This can be a spectrum of deformity and how bad the deformity is, tells us what surgeries that we'll do. And you'll see that even in the mild ones, there's like five surgical procedures that we're going to do for that child all at one time. But it's still a lot of surgery to the foot. And the more severe the deformity becomes, the more we're going to more surgery. we're going to need to do for that child. And then in our last bit of time here, we're going to talk about my least favorite topic, which is juvenile Alex valle Ghous, which is otherwise known as adolescent bunions, unions of course, are, you know, greater than 15 degrees of val, just alignment of the great toe, relative to the first metatarsal. So this is the Alex valdas angle that I'm marking out here and they get this medial prominence of the of the first metatarsal head. Yeah. Um really in house val Ghous, there's no real consensus on the best surgical treatment, but what there is consensus on is that we should not be operating on skeletal immature bunions. So there's a greater than 60 and probably more than that percent recurrence rate if you operate on juvenile bunions or adolescent bunions. So we try very hard not to do it and we would never operate for the purposes of Cosme Asus on a child. If they don't like the way they're foot looks just because they have bunions. Um They don't get surgery out of us. We operate for pain and if their skeletal mature um these are usually bilateral, much more common in females than males, usually a strong family history. And there's a variety of factors that can contribute to the development of bunions, with genetics being the biggest one. Um Also ligament laxity. So if they have a flat foot that can drive the can deviate the toe outward and help contribute to a bunion. And then of course you wear. Um And so when we look at this clinically, you know, we got to sort out if it's a pain issue or a cosmetic issue. Um And if they if they have a lot of redness and swelling over that first metatarsal Flandreau joint, that means the shoes are too narrow. And that's like a big problem to the kids are wearing too narrow shoes these days. They wear them for fashion, not for function. And so it's really great to take the shoe from the other foot, put it up against the bottom of of the opposite foot, because then the shoe lines up and you can show the family how much wider foot is relative to the shoe. And it's not a wonder that that area hurts. Um, So check the shoes, make sure they're wearing the right ones. We rule out other reasons for having a bunion. But for the most part, again, it's just um, it's a family history. That's the most significant contribution. We would get x rays if they were referred into us. And we just measure a ton of things which you don't need to know about. But just know that bunions are not as straightforward as people think they are, and actually they're quite difficult. They can be quite difficult in reconstruction. So basically the treatment for bunions is to avoid surgery and the skeletal immature child to use wide toe box shoes, avoid any kind of high heels, toe spacers and other splints can be tried, but in most kids and adults, they're ineffective. Um Those with with a flat foot. This is the one time where I might have them use an arch support. And let me be clear. I would never recommend a rigid arch support for any child with a flat foot. Um like the kind that you get from a podiatrist. So those hard, rock hard uh orthotics. I would never recommend. Um the nice over the counter soft arch supports or what we were talk what we would talk about and then if the heel cord is tight, then stretched those Um basically non operative treatment. Non operative treatment. Non operative treatment. Only if pain persists and their skeletal immature. What we consider surgery, there's over 125 procedures described for bunions. And so it's kind of the surgeons dealer's choice on this and there's a lot of complications that can happen, which is why we only operate if we absolutely have to. There's a variety of other foot conditions which we are not going to have time to talk about. Such as breaking metatarsal, which is shortening of one of the rays, like you can see on the child's right foot. She actually had it on the other foot, but I lengthen to that one. Um And so now it looks normal. And yes, I did the surgery on the other side. Um So uh there's curly toe which is very common in little people like youngsters, which is usually the 3rd, 4th and 5th toes are involved. It can be very bothersome to the parents but usually totally asymptomatic only if it persists into, you know older than 3456 and it becomes symptomatic. Would we do anything for curly toe? Course there's Polydor actually of the foot, both pre axle and post Axelle pollet actually. And we do take extra toes off mostly because we are a shoe wearing society. And it's hard to find shoes when you have extra toes. There's one you can have less toes than normal. And with only God actually, the that those are important to refer because their whole leg needs to be evaluated because those can be associated with a 50 dealer or tibial him Amelia. And so we have to make sure that the ankle and above are normal in the setting of Holy God, actually there's MAC radioactivity, which is overgrowth of one or more of the toast. And so in summary who to refer. So newborns and infants we're going to refer right away. The club feet and the congenital vertical tail list. If you know that they have a congenital vertical tails or you suspect it, you're going to refer if not improving over the first six months of Falconio valdas foot or a stiff metatarsal abduct us towards the end of the year, the first year of life. Then we would want to see the poly dactyls. The syndicate would go to plastics and very rarely do toast and activities need surgery by the way because you just don't need your toes to be separated. They're not that like um sort of agile of a digit. They're not like the hand, but politifact Elise, we often will operate on age one or older uh metatarsals that does this, that somewhat stiff but not and not improving. You're going to refer obviously the stiff ones you referred earlier and then older kids, a painful flatfoot, flatfoot with a tight achilles tendon that hasn't gotten better with stretching any high arched foot is going to need to get referred. A symptomatic curly toe. So an older kid with a persistent symptomatic curly curly toe. Breaking metatarsal because those can develop transfers metatarsals of foot pain. Symptomatic accessory particulars. Obviously if it hurts, we're happy to see them. And then um just a reminder to get a screening hip ultrasound on babies with metatarsal seductress and cal colonial valdas foot. And of course if the child is breach and also if they have to go to college or congenital, lead this location. Those are the things that that we get screening hip ultrasounds for. This is our team of pediatric orthopedic surgeons. And then we have to uh sorry three primary care pediatrics, sports doctors which are dr chang dr Deborah and DR Watkins. The rest of us are surgeons uh and we are on both sides of the bay in multiple locations throughout the Bay area, more than happy to take care of your of your patients and answer any questions that you have. This is how you go about referring to us.