Common Foot Problems in Pediatric Patients

By: Erin Klein, DPM

I have had the pleasure to treat many children here at the Weil Foot and Ankle Institute and have found that the problems pediatric patients face can be very different than those of adults. Much like children’s shoes, pediatric foot problems come in all shapes and sizes. The physician that treats children’s foot problems needs to be attuned to the way children communicate, as well as the special needs of our littlest patients.

The six common problems we see in our pediatric patients here at the Weil Foot and Ankle Institute are: flatfeet, intoeing, gait problems, heel pain, infected ingrown toenails and warts. I have provided an overview of each condition, as well as treatments that we use to solve these common pediatric foot problems.

Infected, ingrown toenails:

An ingrown toenail is a toenail that has curved in at the medial and lateral sides of the nail. It digs into and can cause a break in the skin. Bacterial infections of the ingrown toenail are a potentially serious condition that requires medical attention. When children with infected, ingrown toenails come to see me, many have already seen at least one other medical professional and may have already been placed on antibiotics that really didn’t help. Infected, ingrown toenails are one of my favorite problems to treat in pediatric patients because with a small procedure done in the office, children can be back on their feet rather quickly.

In order to do this small, in-office procedure, we inject the toe with local anesthetic. Pediatric patients, young and old, may yell, scream and carry on while we perform the injection. I’ve seen that this can be a bit embarrassing to parents – but – I don’t blame the kids for screaming. If you stuck a needle in my toe, I’d have to scream too! The reason we do this is not to torture kids, but to rid the cause of the bacterial infection (the ingrown nail) and irrigate the area. This will help the infection to clear and have the child pain and infection free in little to no time.

Flatfeet, intoeing and gait problems:

I see pediatric patients with complaints of flatfeet and gait problems everyday. Sometimes, this is a medical problem that needs to be treated, other times – not so much. It is perfectly normal for children to have flatfeet or walk slightly intoed. Many times this is painless and will resolve (somewhat) with age. There is no evidence in medical literature to suggest that flatfeet or a slightly intoed gait will prevent a child from being able to walk, run or live a full and healthy life.

Flatfeet and intoeing become problematic when they cause children to have pain in their feet, feel that their legs tire easily with activities such as walking, running or playing with their friends, or have excessive wearing on the soles of their shoes. Children that refuse to walk or “don’t wanna” walk may be experiencing pain in their feet or legs, and just don’t know how to communicate that to their parents. If you would like to find out whether or not your child’s flatfeet, intoeing or gait problem is problematic to his/her overall foot health, be sure to contact one of our Weil Foot and Ankle physicians to schedule an evaluation.

Heel pain:

Pediatric heel pain is not a condition to take lightly. Although children rarely experience heel pain in the same way adults do, it is still important to have the area examined and properly diagnosed.  Please contact your Weil Foot and Ankle physician immediately if your child is experiencing heel pain, as this may be a serious condition that requires treatment. Most of the time, pediatric heel pain is related to inflammation of the growth plate in the heel bone. This is easily treated with rest, ice and stretching. There is the possibility, however, of a more serious condition in which pediatric heel pain is caused by an infection in the bone.

Warts:

Warts are tricky and can be very frustrating to treat in pediatric patients. Warts are a dermatological manifestation of a virus that can be acquired at the pool or beach in the summertime, or on any wet, damp surface that is used by multiple people (i.e. locker rooms). Warts can be extremely painful as they are often located at pressure points in the foot and have their own blood and nerve supply. There are many options for treatment of this problem – the most important part of treatment being, keeping the area of the wart dry. Why? Warts prefer warm, moist environments. If you remove the moisture (sometimes it is hard to remove the elevated temperature), the warts will not grow as readily and the body can start to help remove them from the area.  We have some wart removal products (Pedinol and Plantarstat) available in our online store that may assist in drying and ultimately removing the wart.

Challenges unique to treating children.

Treating children is quite fun, however, it can also be extremely challenging. Kids don’t think, feel or communicate the way adults do. They get scared that they won’t be able to walk again, they won’t be able to play with their friends again or, most commonly, that “it’s gonna hurt.” Kids also get worried that I, as a physician, won’t believe that they are in pain. They fear that if they admit that they are in pain or hurting, their parents will feel bad – and kids don’t want that.

My personal approach is to listen. Kids can communicate – in their own, uniquely kid way – and, if you listen, you will hear. I also enjoy playing with some of my youngest patients (pretty much anyone under the age of 3). This way they don’t realize that I am examining them and learning about their problems, and they don’t have to sit in the scary grown-up examination chair.

The best part about treating kids is their unique ability to brighten just about any day. I mean, how can you be that big of a grump when a 4-year-old hands you a hand-drawn picture of a dinosaur, or when a 6-year-old colors you a picture of a goofy looking doctor, or when one of your teenagers makes you a duct tape stethoscope and medical bag just for fun, or when a 2-year-old decides that you need a hug? You can’t be grumpy after that! J

Erin’s Top 10 Things She Loves about Treating Kids:

1. They say thank you.
2. They WANT to get better
3. They can be so cute!
4. They do goofy things like draw you pictures and make you duct-tape stethoscopes – and this really makes my day.
5. They speak simply, in terms that actually make sense to me.
6. They smile, giggle and make funny faces.
7. They give good hugs – especially kids in the 2-year-old age range.
8. They are amused by the simplest things – like head, shoulders, knees and toes…. which little piggy went where…. playing ball in the hallway…(They have no idea that I’m examining them while I’m doing all of this either!)
9. Lollipops and suckers can cure anything.
10. I think I might just be a little kid in a grown up’s body!

Hello Spring, Hello Heel Pain??

By: Lowell Weil, Jr., DPM

The baseball season, which marks the unofficial start of spring, is finally here.  Actually, this year in Chicago, spring has started very early with unprecedented great weather in March.  Usually we are still hunkered down with frigid temperatures, hoping and wishing for just a glimpse of spring to arrive.  Spring means many things to different people, but to those who take care of feet at the Weil Foot & Ankle Institute, it means the beginning of PLANTAR FASCIITIS SEASON.

Plantar Fasciitis is that annoying pain to the bottom of our feet, particularly in the heels, that grabs us when we get out of bed in the morning or get up from a rested or seated position.  Oh, it starts out slowly and we think we just have a heel bruise that will go away, but a month or two later we realize not only has it not gone away, your heel pain has actually gotten slightly worse.  Now we are limping a bit in the morning and have cut back on exercise, which is annoying because we know how important exercise is for our overall health.

Why is the onset of plantar fasciitis so prominent in the spring, you ask? The primary reason is that as the weather gets nicer, people want to get out and enjoy it.  Gardeners will take to their gardens for priming, pruning, and planting. Runners and walkers will begin more intense workouts embarking on faster times and longer distances. Golfers will hit the links with more vigor, and many of us will simply get out those sandals that we love, which, by the way, don’t offer much support for our feet.

But why do those things cause heel pain?  Well, heel pain/plantar fasciitis is most frequently caused from tight calf muscles and heel cords.  We get tight calf muscles for several reasons.  One reason is that as we get older, we inevitably get less flexible.  Another reason is that we rarely stretch regularly, even those of us who do yoga. The tight pull of the calf muscles and heel cords causes stress to the plantar fascia, a tissue on the bottom of the foot that connects to the heel bone.  This irritation to the plantar fascia may cause very small tears that result in pain and swelling. When our calf muscles are too tight and we increase our activities, this all results.  Soft surfaces such as grass or sand make heel pain/plantar fasciitis worse by causing our heels to sink downward and putting more stress on the tissues.  To some degree sandals, flip-flops and bare feet do the same thing and do not provide much support.

So now the question you've been waiting for: What do you do if you start getting heel pain?  There are some easy steps you can take to alleviate your heel pain and prevent it from worsening. 

1. Wear shoes that give more support.  A running shoe (I said running shoe, NOT just gym shoe) will provide excellent support and slightly raise the heel to relax the calf muscle.  Wearing shoes with a slight heel can really help.  Look for something that has 1-1.5 inches of heel.
2. Avoid bare feet, slippers, sandals and flats…until your condition gets better.  There are some good sandals, here, that have support that you may want to try out. There are also arch supports (Orthoheel and Powerstep) that can be purchased on line that are better than what is offered in the pharmacy.
3. Increase your stretching. Start stretching your calf muscle 3-4 times a day. See this site for useful stretches.
4. Use conservative treatment to alleviate symptoms. Take over-the-counter anti-inflammatory medicines (Ibuprofen, Aleve, etc.) as directed on the bottle consistently for a week or so.  Putting ice on the area for ten minutes at a time, once or twice a day will also help.

So what happens if your heel pain persists?  If your pain does not subside within a week or two, you face the possibility of having a chronic problem.  That is where physicians from the Weil Foot & Ankle Institute come in.  Physicians at the Weil Foot & Ankle Institute are renown for their treatment of heel pain.  The doctors here have done many studies, published papers and books and lectured around the world on heel pain and plantar fasciitis.  They have treated professional athletes from the Chicago Bulls, Chicago White Sox, Chicago Bears and other professional organizations, and Olympic and collegiate athletes from around the country for plantar fasciitis.Weil Foot & Ankle Institute Physicians have pioneered non-invasive and minimally invasive treatments for the treatment of plantar fasciitis. (See treatment options here and here).  They can create a specialized treatment regimen to meet your daily needs and successfully rid you of heel pain.

So as spring creates optimism for our typically disappointing baseball teams, don’t let your heel pain get you down. Protect your heels with the steps we’ve mentioned, and if that heel pain persists, come see one of our doctors at the Weil Foot & Ankle Institute. They’ll have you out and enjoying the weather, free of heel pain, before you know it!

Lowell Weil, Jr., DPM, MBA, FACFAS Fellowship Director, Weil Foot & Ankle Institute

Team Podiatrist, Chicago White Sox 
Dr. Weil Jr. has been on the staff of Weil Foot & Ankle Institute since 1996. His special areas of interest are reconstructive foot and ankle surgery, tendon and ligament reconstruction, radiofrequency techniques, Extracorporeal Shock Wave Therapy and sports medicine.

Shockwave Therapy Effective for Treating Heel Pain

FOOT AND ANKLE
ORTHOPEDICS TODAY July 1, 2010

Shock wave therapy effective for chronic heel pain in randomized, prospective trial
Visual Analog Scale pain scores at 12 months post-treatment dropped 7.5 points from baseline and those patients reported no major adverse events.

Investigators for a multicenter study found that extracorporeal shock wave therapy safely and effectively reduced recalcitrant chronic plantar heel pain, according to findings from their randomized placebo-controlled trial.

“The focused extracorporeal shock wave therapy (ESWT) as applied in this study shows statistically and clinically relevant results with a much better outcome in the active group,” compared to the control group, Ludger Gerdesmeyer, MD, of Kiel, Germany, said at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons in New Orleans.

In the ESWT study group, “We have found no relevant side effects,” Gerdesmeyer said. The data he presented have been submitted to the U.S. Food and Drug Administration for possible clearance of the Duolith SD1 (Storz Medical) used in the study for this indication.

The 250-patient study was conducted at European and U.S. centers. Investigators enrolled patients from each center with chronic plantar heel pain of greater than 5 on the Visual Analog Scale (VAS) that did not respond to conservative care.
Focused ESWT

After a wash-out period, patients were randomized to either the active or control group. The active group received 0.25 mJ/mm2 ESWT, 4 Hz frequency, with the device focused on the site of heel pain without the aid of any radiography. Patients in the control group underwent a sham treatment where the ESWT device was deactivated but used identically.

Patients underwent three treatments each. Their results were assessed at 3 months and 12 months following their last treatment using the VAS pain scores as the main outcome measure. Results of the Roles and Maudsley patient self-assessment score and the SF-36 score served as secondary outcomes.

At 3 months, baseline composite VAS scores of 8.3 decreased to 2.7 points after ESWT in the active group and decreased to 5.3 points in the control group. In the ESWT group, VAS scores further decreased after 12 months to 0.8 points.
Less pain

“In the active group we have 69% of the patients [having] more than 60% pain reduction compared to baseline,” Gerdesmeyer said. By comparison, sham treatment was associated with more than 60% pain reduction in 34% of control patients, he said.

Differences between the baseline and follow-up secondary outcomes also favored the active group.

No major adverse events occurred related to ESWT treatment. Some patients treated with ESWT, however, reported device-related events including slight pain or discomfort during and after treatment and minor local swelling or redness.

“It was interesting to see that placebo patients getting just a sham treatment also reported pain during treatment,” Gerdesmeyer added. — by Susan M. Rapp

Reference:

* Gerdesmeyer L, Gollwitzer HW, Saxena A, et al. Focused shock wave therapy in chronic plantar heel pain: A randomized placebo controlled trial. #706. Presented at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons. March 9-13, 2010. New Orleans.

Ludger Gerdesmeyer, MD, can be reached in the Department of Orthopedics and Traumatology, Klinikum Recht der Isar, Technical University Munich, Insmaniger Str. 22, Munich, Germany; 49-89-41402271; e-mail: gerdesmeyer@aol.com.

Perspective

Carol C. Frey, MD
Carol C. Frey

Published studies report that more than 2 million patients are treated for plantar fasciitis each year, accounting for approximately 11% to 15% of all foot-related encounters with physicians annually. Plantar fasciitis is a painful inflammatory process that when not treated can evolve into chronic degenerative changes in the fascia. Traditional treatment options, including conservative measures and medication, have shown success rates from 44% to 82%. Surgical intervention with open or endoscopic release of the plantar fascia has unpredictable results, substantial risks and recovery is usually very slow — 1 year. Researchers have been building a strong body of published clinical evidence for ESWT. ESWT has been shown to be safe and effective in several prospective randomized studies including studies by Gerdesmeyer. In cases of failed nonsurgical treatment, ESWT represents an excellent option to surgery and radial ESWT may be a better option than focused ESWT, as anesthesia is not required.

– Carol C. Frey, MD
Foot & Ankle Section Editor
Orthopedics Today

Study Shows ESWT an Effective Non-Surgical Alternative

The doctors of the Weil Foot & Ankle Institute have studied, published on and utilized Extracorporeal Shock Wave Therapy (ESWT) for years to treat patients with heel pain and other painful conditions of the foot and ankle. The studies commented on below are another confirmation that ESWT can be an effective non-surgical alternative to treating pain. From Orthopedics Today:

Published studies report that more than 2 million patients are treated for plantar fasciitis each year, accounting for approximately 11% to 15% of all foot-related encounters with physicians annually. Plantar fasciitis is a painful inflammatory process that when not treated can evolve into chronic degenerative changes in the fascia. Traditional treatment options, including conservative measures and medication, have shown success rates from 44% to 82%. Surgical intervention with open or endoscopic release of the plantar fascia has unpredictable results, substantial risks and recovery is usually very slow — 1 year. Researchers have been building a strong body of published clinical evidence for ESWT. ESWT has been shown to be safe and effective in several prospective randomized studies including studies by Gerdesmeyer. In cases of failed nonsurgical treatment, ESWT represents an excellent option to surgery and radial ESWT may be a better option than focused ESWT, as anesthesia is not required.

– Carol C. Frey, MD
Foot & Ankle Section Editor
Orthopedics Today

IL Podiatrist Questions Heel Pain Study's Conclusions

Women who habitually wear high heels have shorter muscle fibers in their calves and thicker Achilles' tendons than those who walk in flat shoes, researchers say. The result? The heel lovers’ tendons stiffen and become harder to stretch, which could explain why walking hurts after kicking off the Jimmy Choos, according to a small study published in the Journal of Experimental Biology. The researchers found that wearing heels affected muscle fiber length--the high heel wearers' muscle fibers were 13 percent shorter than those who wore flat shoes. For some women, once the heels come off, the pain starts because the muscles can't stretch enough, the researchers said.

Wearing a variety of different types of shoes and stretching may help alleviate the pain, according to the study authors. But Chicago podiatrist Steve Weinberg, who was not involved with the study, questioned whether it's possible to stretch the Achilles tendon enough to make a clinical difference. "If women are going to wear high heels, they should be prudent—stand or walk in them for a short time,” said Weinberg, a podiatrist at the Weil Foot & Ankle Institute and the longtime chief podiatrist for the Chicago Marathon.

Source: Julie Deardorff, Chicago Tribune [7/16/10]

Treating Heel Pain with ESWT: Our Happy Patients

Hey Doc! I am writing to let you know of my ESWT and office visits from start to finish. When I got there on my first visit I liked the fact that you were straight forward and didn’t try to sell me ESWT and let me know it was not a covered (insurance) item. I had just gotten a shot from my referring doctor so my foot was feeling good. You introduced me to Jennifer and said when and if I decide to do something please call her and she will take care of it from start to finish. She did.

I called several months later and came in and got my first treatment followed by the 3 other two a few weeks apart and we talked every time and I did feel like you were really listening and wanted to let you know I appreciated that. Still and all my foot was not feeling as good as I would have liked. Once again you took the time to listen and we talked about a moving forward game plan. From here is where I really to emphasize my treatment by your staff; in particular Jennifer (She was great!!). The plan was to send in for insurance approval for orthotics. Jen had me get molded so that if they approved them then you get them done and I could come back when complete and be good to go. She said if they say no, we will go to Plan “B” which was using my fourth “freebie” ESWT, and then see how that took and go from there to Plan “C”, which was surgery.

I was called the next day by someone and told that insurance wouldn’t cover the ortoics and if I wanted I would have to pay $550 now. I said to hold them and I will think more on them and get back with them. Then I asked to speak to Jen and schedule the fourth ESWT treatment. I really thought this would be a hassle or was thinking something would be less than before being on you. It was not and you handled it just like normal and one of the things I want to report in this letter is the fourth time was the charm and my foot has felt 100% better since.

Everything seemed great until…I got a bill wanting me to pay approx. $125 for my part of the bill for work that was never done and what the insurance didn’t cover on the orthotics that they did pay for. I called and talked to someone who I’m sure was more than happy to hand this over to Jen to take care of. (I was not happy) The first thing Jen said was will take off everything on this bill that’s not right and make everything right.

She had me come in for another fitting which did not have the office co-pay since I was there before for that. (A cheap guy like me appreciates that). Made the next appointment for the fitting and said if I had any issues on the bill we will finalize them after the fitting. Today after the fitting she walked me out to the waiting area, spoke to Lindsay personally and had her correct the bill to what made sense and then had Lindsay (who was also very nice) go over the bill with me in detail. Then Jen stopped back in and made sure I was a “happy camper”. This was the right thing to do, the professional thing to do, and the nice thing to do. They took a wrong and made it right. Please accept my compliments on your work, Lindsay’s work, and especially Jennifer’s work. She is the best! Please feel free to share this and use me for any reference.

Thanks,
Bob
Franklin Park, IL