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Three
Articles On Children's Feet
(Including Bunions at Bottom)
ACORN June 1993
A Few Words about Little Feet
By: Michael Zapf, DPM, MPH, FACFAOM
This being the children's issue of the ACORN it is the perfect opportunity
to write about two of my favorite topics: children and feet. It is also a chance to rerun
the ad I made a year ago featuring my little Christopher's actual foot print. He is a
little over one year old and his feet are holding strong. He is standing and cruising and
will be walking and running any day. I hear from many of you that my life will be forever
changed when he becomes bipedal.
Two weeks ago I had the pleasure to meet Ari. He is an almost three year
old who came to my office with his mother. Mom has been concerned about Ari's feet since
the day he was born. She thought there was something a little wrong with their shape.
Unfortunately Ari's doctor dismissed mom's complaint with a statement that
she should not worry and that Ari will grow out of it. Although heard much less
commonly today than in the past, this phrase is responsible for a lot of adult and
adolescent foot trouble.
Every foot doctor will tell you that many foot complaints, including
bunions (especially bunions in children), hammertoes and heel and arch pain, can
frequently be attributed to a faulty shape or biomechanics of the foot. In medical terms
the problems include metatarsus adductus, forefoot or rearfoot varus and hyper-pronation.
In lay terms, the foot is shaped funny. The abnormal shape is usual very obvious once it
is pointed out. Most of the time the abnormal shape was present at birth and most of the
time the patient's parents heard the admonition "don't worry, they'll grow out of
it." The truth is, they don't always grow out of it. And it is nearly
impossible to tell who will and who will not. My best advice is, if your child acts like
he or she has foot problems, or if you see what looks like a potential problem, have it
evaluated carefully. And remember, not everyone grows out of it.
Next month we will discuss the treatment for these problems. You might be
surprised to learn that treatment is not complex. It usually involves a change in shoes
and possibly wearing an in-shoe support called an orthotic. The best part of the treatment
is that it doesn't hurt and cannot harm your child. The worst it can be is unnecessary.
The best it can be is saving your child a lifetime of foot discomfort.
Symptoms of a child with foot problems:
· Complaint of "growing pains" or
pains or cramps in the feet or leg at night
· Dislike weight bearing activities and prefer
to sit, ride or be carried
· Frequent falling or tripping
· Poor balance or posture
· Reluctant to walk for long periods
· Limping
What to look for that might indicate a foot problem in a child:
· "Turned out heels" where the
heels that from the ankles down point away from each other when looking from behind. (Hard
to describe but easy to point out)
· Wide feet that are difficult to fit with
shoes
· A foot that does not appear to be directly
under the leg.
· A foot that seems to bulge below the inside
ankle bone.
· Knee caps that point toward each other
instead of straight ahead.
· Absent or low arch height.
· The bottom of the foot is not straight but
curved like a kidney bean
· The big toe is rotated so the toe nail is
not facing straight up.
· A bunion is forming where the big toe is
leaning toward the lesser toes and there is a slight bulge on the inside of the foot
behind the big toe.
Dr. Michael Zapf is a podiatrist in private practice in Agoura Hills
and Thousand Oaks. He specializes in the foot care of adults and children. For more
information, please call his office at (818) 707-3668.
ACORN June 1994
The Mysterious Feet of Children
By: Michael Zapf, DPM, MPH, FACFAOM
I love solving mysteries. For years I have noticed a curious phenomenon
with little boys in the office. Without fail, when the shoes are removed sand pours out
forming a little pile on the floor. We dutifully take the portable vacuum to the floor,
but some sand always remains. For the rest of the day I feel like I am Dr.. Fred Astaire
doing a soft shoe dance routine.
. I always thought that these little boys must have just come from the
park, but I was wrong. Now that I have a little boy of my own, I know the secret. Even on
days when we have not been within a mile of a park, Christopher’s shoes are filled
with sand. I know that the feet of adults sweat and the feet of little girls perspire. I
cannot prove it scientifically but the feet of little boys must excrete sand! Nothing else
can explain it. I daydream that the sand at the beach was not caused by the erosion of
larger rocks. Instead it is the result of hundred of generations of mothers and fathers
washing the sand filled socks of little boys. The sand gets into the water supply and
finds its way to the ocean. Presto, you have formed a beach.
Speaking of young children, I spent last Saturday in a clinic in
Mexicali, Mexico. I belong to a group of podiatric surgeons who travel down to Tijuana or
Mexicali every weekend to care for the foot problems of local children. For three weeks of
the month we hold a Saturday clinic. The fourth weekend is the surgery session where we
perform up to eight surgeries on children as young as five months of age. We see a
tremendous variety of foot problems in these children from ingrown nails to congenital
deformities like club feet and everything in-between.
Last Saturday was a clinic session where we cared for over 40 children.
The most common complaint I heard in Mexicali was one I hear almost every week in my
stateside offices: children who trip and fall when they walk or run. These children are
otherwise bright and healthy and usually less than ten years of age. The parents are
concerned that their child is not as active as his or her peers and that they usually have
noticed some variation in the appearance of the lower extremity. In the United States the
parents have usually talked these findings over with the pediatrician. In Mexico the
children rarely have a pediatrician.
The list of things that can cause a child to trip and fall is very
extensive. Fortunately, some of the most severe reasons are also the most unusual and can
be ruled out rather quickly. The majority are due to a hip joint that allows more inward
rotation of the leg than outward. This causes the leg to be a bit internally inward. In
such a situation the knee caps appear to point toward each other (squinting patellae)
rather than straight ahead. This also caused the feet to roll inward (pronation to the
podiatrically sophisticated). This inward rolling of the feet makes the them unstable
contributing to the tripping and falling. In short, the hip position pronates the feet
resulting in instability.
Almost always the hip position will correct itself in time and is
usually not a major cause of concern. Problems do occur when children pronate excessively
while waiting for the correction to occur. These children not only trip and fall but can
develop complaints of foot and leg pain and night cramps. These are often attributed to
growing pains. If problems are particularly bothersome, treatment should be considered.
This scenario can be reversed if the foot is kept from pronating more
than it should. Sometimes this can be done with a good pair of shoes, preferably with good
quality athletic shoes. Other times a little more help is needed. We can supply that help
with shoe modifications in infants and toddlers and orthotics for the older child. An
orthotic is a support made from a plaster cast of the foot held in a position designed to
eliminate the problems. It is worn in the shoes and is virtually undetectable.
In addition to supporting the foot, a few other changes are suggested.
Because it feels so comfortable, these children often sit in a reverse "W"
position where they are practically sitting on their feet. This accentuates the inward
position of the legs. To encourage an external force on the hips we encourage the child to
sit like an Indian where the legs are crossed in front of them. Rollerblading,
roller skating, ice skating and ballet also encourage external rotation of the hip joint.
With all of these tricks we can usually minimize tripping and falling
in young children. Now if these techniques would only help "Dr. Astaire" when he
is walking on all that sand.
P.S. Speaking of Mysteries, the Conejo Free Clinic is holding a
Fabulous Murder Mystery Dinner and Auction at the Lake Sherwood Country Club on September
30, 1994 for a very reasonable donation. Please call my office if you would like to
receive an invitation to attend the dinner.
Dr. Michael Zapf is a board certified podiatrist in practice in Agoura
Hills and Thousand Oaks. For more information please call his office at (818) 707-3668 or
(805) 497-6979.
ACORN March 1994
Children’s Bunions
By: Michael Zapf, DPM, MPH, FACFAOM
Kim, Alexis and Danielle are alike. They go to local junior high schools, love the
mall, are active in sports. Unfortunately, they also all have bunions.
So you thought bunions are only for adults? That they are the big, painful bulges on
the inside of the foot behind the big toe that only those of us over thirty get? Well you
would know that is not true if you met these three delightful young ladies.
Children’s bunions can get every bit as large as the adult counterparts. What sets
them apart from adult bunions is their increased severity. Forces that can cause a bunion
in seven years are obviously stronger than ones that take thirty or forty.
The forces causing children’s bunions are almost always related to pronation
(known as flat feet to the podiatry impaired). Flat feet always cause some foot
instability. The instability causes the foot to splay and allows bunions to form. True,
not every flat foot develops a bunion, but, it is rare to have a child with a juvenile
bunion without flat feet. Flat feet are fairly common and, unfortunately, there is no
reliable way to predict who will develop a bunion. To explain, let me tell you a little
more about Kim.
Kim is a delightful and animated 13 year old softball player. She came
to my office for the treatment of painful warts. During our initial examination I
couldn’t help but notice that she had a large bunion for someone so young (see
photograph). In addition to the bunion, her big toe was leaning over and nestled somewhat
under the second toe.
Kim’s mother said she knew her daughter had an unusual foot shape but did not know
it was a bunion. She pointed it out to her daughter’s doctor and was told that it was
a normal variation and that Kim mold most probably grow out of it. While many pediatric
lower extremity problems do seem to work themselves out with maturity, bunions are not one
of them. Juvenile bunions, like all bunions for that matter, never get smaller and usually
get larger with time.
Unlike adult bunions, juvenile bunions frequently do not hurt and Kim said hers has
never hurt. I see this as a mixed blessing. I am happy that she did not suffer pain. But
the lack of pain caused her and her mother to discount the problem and not seek any
treatment even as it got larger.
So what is done for a juvenile bunion? Certainly surgery is an option for very large
and painful bunions. While Kim’s is large, it is not painful. She plays, runs, dances
and shops as though nothing was wrong. If it ever hurts, we will take care of it
surgically when her bones are a little more physiologically mature.
Until then it would be nice to stabilize the foot, make it function better and, if
possible, keep the bunion from getting larger. Fortunately this can be done with an
orthotic.
An orthotic is a custom made in-shoe support that simply keeps the foot from pronating
excessively. Limiting excessive pronation has many benefits. It will reduce stress on the
knees, especially if they are rotated inward. An orthotic can take the stress off of leg
tendons easing the pain of shin splints. An orthotic can relax the pull of a ligament on
the bottom of the foot to relieve heel spur and plantar fascia pain. Fortunately, an
orthotic can also slow or stop the development of bunions, especially if they aren’t
too large. For Kim it may be too late for the large bunion on her left foot. But the one
on her right foot is much smaller and might well respond to an orthotic.
. For children with flat feet and a bunion, or a family history of bunions, I recommend
an orthotic. For children with flat feet and no bunions I advise caution. An orthotic can
never hurt and has every likelihood of helping. At the very worst it could be considered a
needless expense if bunions or other foot problems fail to occur. The trick, of course, is
predicting just who will need one ahead of time. This is no easy feat.
As for Kim, she has her orthotics. She is pitching up a storm, And she can walk for
hours at the mall. She seems pretty happy as she bides her time with her bunion.
Dr. Michael Zapf is a board certified podiatrist in practice in Agoura Hills and
Thousand Oaks. For more information please call his office at (818) 707-3668 or (805)
497-6979.
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