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Metatarsus Adductus (Metadductus)

What is a Metatarsus Adductus?

What is a Metatarsus Adductus?

Looking at the bottom of a newborn’s foot, you’ll notice the inner border of the foot curves slightly off-center. This is normal and not to be confused with any foot deformity. By the time the baby reaches 4-6 months old, the foot usually straightens out on its own. Otherwise, the infant may have metatarsus adductus.

Also known as metatarsus varus and MTA for short, metatarsus adductus is a condition where the front half of the foot, or forefoot, is angled inward relative to the hindfoot (or heel). The bones in the middle of the foot bend in toward the body, slanting the forefoot toward the midline while leaving the midfoot and hindfoot pointing straight ahead.

The incidence of MTA is reported to fall between 0.1 and 1 percent of live births. Babies born with metatarsus adductus may also have a higher risk for developmental dysplasia of the hip (DDH), a condition of the hip joint in which the top of the thigh (femur) slips in and out of its socket because the socket is too shallow to keep the joint intact.

What Causes a Metatarsus Adductus?

The probable origin of MTA is how a baby’s feet are turned in persistently while held in the womb. The forefoot at this stage is very flexible, so pressing against the uterus wall bends and shapes it into a curve. The condition improves over 6-12 weeks after birth in nearly all children when their feet become unrestricted and free to move. In about 10% of cases, however, the deformity becomes less flexible and turns into a metatarsus adductus.

A baby’s sleeping position may contribute to the condition, since babies sleeping on their stomach may increase the tendency of the feet to turn inward.

Who Gets a Metatarsus Adductus?

The risk factors for metatarsus adductus include:

  • Babies born in the breech position (buttocks or feet coming out first)

  • Genetics, as babies with a family history of metatarsus adductus, tends to have a higher chance of developing the condition

  • A condition called oligohydramnios, in which the pregnant mother does not produce enough amniotic fluid to nurture and cushion the unborn fetus sufficiently in the womb

  • Firstborn children are more likely to have MTA

  • Female infants are slightly more likely than male infants

Are There Different Types of a Metatarsus Adductus?

Usually, metatarsus adductus is divided into two categories:

  • Non-flexible, in which the angling of the forefoot is fixed (because the bones are slanted toward the midline) and cannot be straightened by hand

  • Flexible, where the misalignment can be straightened to a degree by hand by pulling on the front part of the foot (because the bones are not fixed in a slanted angle in their attachment to the midfoot)

What are the Symptoms of a Metatarsus Adductus?

The primary sign of a metatarsus adductus is that the front of the foot is bent inward, though the back of the foot and the ankles remain normal. The entire foot is shaped like a banana or the letter “C”. The base of the fifth metatarsal (toe bone), called “styloid”, is prominent and sticks out as a bony “bump”. Usually, there is an abnormally wide space between the big toe and the second toe, because the first metatarsal (toe bone), attached to the big toe, is the only slanted bone. The foot has a high arch. Metatarsus adductus is very often evident by the crease at the midpoint of the inner border of the foot, between the forefoot and hindfoot where the turning in occurs. About half of children with MTA have the problem in both feet.

How do You Diagnose a Metatarsus Adductus?

A physician makes the diagnosis of metatarsus adductus with a physical examination. The physician will get a complete birth history of the child and ask if other family members were known to have the condition.

The physician will examine the front of the foot and the big toe (and perhaps some of the other toes) to see if they are slanting inward. A common method for infants when their feet are still tiny is the V-Finger Test: The physician forms a “V” with his second and third finger, and tucks the infant’s heel into the V until it touches the base, with the inside of the foot resting against the index finger, the outside resting against the middle finger. This lets the physician observe whether if the midline of the forefoot is abnormally crooked and, if so, how badly by the gap between the forefoot and the middle finger. The physician will also try to passively move the foot by hand into a straight-ahead position. This technique, known as passive manipulation, involves gentle pressure on the forefoot while holding the heel steady. If such manipulation is not successful or difficult, the condition is non-flexible because the deformity is fixed at the toe joint.

X-rays are not typically used in the diagnosis since the condition can be quite discernible to the eyes, but they are often done in the case of rigid/non-flexible metatarsus adductus to check the extent of the deformity.

How do You Treat a Metatarsus Adductus?

Metatarsus adductus diagnosed at birth does not require treatment. It is usually posture-related, and with growth, the condition normally goes away on its own within 6-12 weeks. If the curve is severe, a podiatrist will handle this deformity by placing the baby’s foot in a cast that gently nudges the foot back into its correct position.

For adults with pain or problems linked to MTA, stretching exercises to relieve pain are often recommended. However, if the forefoot does not improve after about 3-4 months of observation and stretching, podiatrists will consider the following treatment options:

  • Special arch support called an orthotic to help balance the foot by placing it in a more normal position.

  • Serial castings are reserved for the very severe and rigid cases. The procedure consists of castings every one or two weeks until the deformity is corrected, which usually takes about 3-4 sets of casts, followed by corrective shoes to hold the correction for about 3 months. This is very time-consuming and expensive.

  • Corrective bracing has recently become a popular option because it avoids the inconvenience and emotional grief that repeated castings can cause.

  • Surgery may be needed if the deformity cannot be corrected by the measures above.

  • Your doctor will decide the timing and method of correction. Once the deformity is corrected, recurrence is unlikely.

Self-Care at Home

First, it’s important to know that 85% of metatarsus adductus resolve without treatment. The “deformity” often straightens out after the foot has the time and space to flex itself, develop, and grow.

A podiatrist can show you how to stretch the child’s foot to help the foot get straighter. The manipulation corrects the deformity faster and typically the only “treatment” you need. If the condition is very noticeable and manipulation is successful, follow up by putting the foot in special shoes to keep it in a neutral position.

When you see the child sleeping on his/her stomach, turn him/her around on his/her back. Sleeping on stomach encourages the feet to turn inward.

Topical Professional Treatments

A physician will determine the specific treatment for your child’s MTA based on:

  • Your child’s age, overall health, and medical history

  • The extent of the condition

  • Your child’s tolerance for specific medications, procedures, or therapies

  • Expectations for the course of the condition

  • Your opinion or preference

When a severe deformity is detected early, i.e., less than 1 year old, the typical treatment combines manipulation and plaster casting for 10 weeks, or up to 6 months of age. Long leg casts, applied from the upper thigh to the foot, help stretch the soft tissues of the forefoot. The plaster casts are changed every one to two weeks by your child’s pediatric orthopedist. For infants of 6 months and older, special padded shoes may be used for arch support and hold the forefoot in place as it heals.

Surgical Treatments

A very severe or rigid case might require an operation to straighten the toe bone at its junction with the middle part of the foot. Corrective surgery should only be performed, however, after the child is at least 2 years old to allow for natural correction. Procedures involving the soft tissue or cartilage are saved for patients of 2-6 years of age, and osseous (bone-related) procedures are reserved for children whose bones are sufficiently mature, at 6-8 years old.

How to Prevent a Metatarsus Adductus?

Since oligohydramnios, a condition in which there is too little amniotic fluid around the fetus is a probable cause, its prevention should decrease the chance of an infant born with severe MTA. This involves good control of maternal diabetes and prevention of infections transmittable from mother to fetus.

Children with MTA may often sit or rest with their legs crossed, or in a “W” position. Encourage the child to sit in a chair with their legs uncrossed instead, though this often cannot be done until they are school age.

Because metatarsus adductus is something a child is born with, there is virtually no surefire way to stop the problem from occurring. However, applying the proper home or professional care will speed up the corrective process.

Pediatric Flatfoot/Talipes Calcaneovalgus

What is a Pediatric Flatfoot/Talipes Calcaneovalgus?

When a flatfoot occurs in children, it is referred to as “pediatric flatfoot.” Its medical term of talipes calcaneovalgus is a combination of talipes calcaneus and talipes valgus. Since “talipes” means a deformity of the foot that you’re born with, “calcaneus” is the heel bone and “valgus” indicates “turned outward”, the term describes the inborn deformity of the foot usually marked by a curled shape or twisted position of the ankle, heel, and toes.

As a form of flatfoot, it has the distinct characteristic of the condition: a partial or total collapse of the foot arch. The flattened inside arch causes the heel bone to turn outward, and as a result, the inside of the foot appears more “bowed” outward than normal. Pediatric flatfoot is not only common among infants and toddlers but somewhat expected because all children are born with a minimal foot arch. It is not a painful condition and will generally resolve without treatment. The need to wear a corrective cast is often unnecessary. Sometimes, though, the arches don’t develop during childhood and you end up with flat feet. Other times, it happens due to an injury or the natural wear-and-tear of aging. You have flat feet if the arch on the inside of your feet is flat enough that your entire feet touch the floor when you stand up.

A child’s foot will start rounding into normal shape around age two or three, as the foot becomes less “fatty” and the bones begin to show more conspicuously. But if the child’s foot still shows no sign of straightening out at this age, it is wise to seek a foot specialist or podiatrist for further examination. Untreated severe flatfoot can force the child’s ankle to turn inward and throw off the alignment of the legs, causing pain when walking throughout the child’s life.

What Causes a Pediatric Flatfoot/Talipes Calcaneovalgus?

A flatfoot is normal in children, especially newborns, for the arch hasn’t yet developed in the foot. Although the exact cause is not known, the main theory for this and other related conditions, like pigeon toes (or in-toeing), holds that an infant’s legs are usually curled up in the cramp space as it grows, therefore causing a minor deformity in the feet as they are pressed into this position inside the uterus.

Most cases of pediatric flatfoot can also be attributed to ligamentous laxity, or loose ligaments and excessively flexible joints in the foot that do not support or hold up the arch well.

Who Gets a Pediatric Flatfoot/Talipes Calcaneovalgus?

Naturally, pediatric flatfoot occurs most frequently in infants and children under two years of age, when the bone structure is not yet developed and the cartilages still soft enough to bend to internal and external pressure. The “deformity” often goes away without treatment once the bones and cartilages firm up and straighten themselves out with age. However, there are other factors to increase the risk of flatfoot:

  • Obesity or overweight. Excessive weight puts a strain on the feet, especially when the child starts to walk.

  • Traumatic injury to the foot or ankle. Any considerable force can easily damage or change the shape of a bone in an infant.

  • Rheumatoid arthritis. Although this painful condition usually does not strike until much later on in life, the crippling effect contributes to developing a flatfoot.

  • Aging. Not a concern for toddlers, but the constant pounding of the foot throughout a lifetime can cause the arch to collapse when we get old.

  • Are There Different Types of a Pediatric Flatfoot/Talipes Calcaneovalgus?

  • There are two types of flatfoot: flexible and rigid.

  • Flexible flatfoot is more common, less severe, and easier to treat (if necessary at all). The child’s arch will look normal while sitting but collapses (or flattens out) when any weight input on the foot. It usually does not cause pain and shows no symptoms.

  • In a rigid flatfoot, the arch appears flat whether the child is sitting or standing. Because it usually indicates a more serious condition, you should take the child to a podiatrist for examination.

What are the Symptoms of a Pediatric Flatfoot/Talipes Calcaneovalgus?

Flatfoot can be apparent at birth or show up years later. Since most children with this condition have no symptoms, many infants who have a “fat” foot are also mistaken by the parents to have flat feet. The most obvious sign is, of course, the lack of flatness of the arch, but other known symptoms include:

  • Pain, tenderness, or cramping in the foot and ankle, particularly in the heel or arch area

  • Swelling along the inside of the ankle

  • A history of clumsiness

  • A tight calf, a common finding in all flatfoot patients

  • Heels pointing or tilting outward when standing

  • Often asking to be carried

  • Avoiding physical activity, and reduced energy when the child does participate

  • Awkwardness or changes in walking

  • Pain when walking or running for any length of time

  • Difficulty standing on tiptoe

  • Problem with shoes; wearing shoes hurt the child’s feet when it shouldn’t

  • Pain in the low back, hip, or knee from the stress of walking on in-turned legs

How do You Diagnose a Pediatric Flatfoot/Talipes Calcaneovalgus?

Pediatric flatfoot can be a deformity fairly obvious to the untrained eye; one can tell by how there’s no arch and the whole foot touches the ground completely when a child is standing. However, it is also unlikely to be properly diagnosed unless by a foot specialist, who is familiar with the structure and working of the foot.

When visiting a podiatrist, have the child wear his/her everyday shoes because the doctor may want to look at the wear patterns on the soles. The doctor may also ask you and the child these questions:

  • When did you first notice any problems with the child’s feet?

  • Where exactly does it hurt?

  • Does anything make the symptoms better or worse?

  • What other medical problems, if any, does the child have?

  • Has the child ever injured his/her foot or ankle?

  • Is there any case of painful flatfoot deformity in the family or family history?

Your podiatrist will then observe the child’s feet from the front and the back, and ask the child to stand on his/her toes. The podiatrist will also examine the feet while the child is standing, walking or running, and both when a foot is bearing weight and without pressure, all to evaluate their range of motion. During the examination, the foot specialist is looking for abnormal structure or function of the foot and lower extremity that can cause both short-term and long-term problems. The doctor may order x-rays of the foot to determine the severity of the deformity, or if a significant disorder is noted or suspected. Because flatfoot is sometimes related to problems in the leg, the doctor may also check the child’s knee and hip.

How do You Treat a Pediatric Flatfoot/Talipes Calcaneovalgus?

If a child has no symptoms, the condition often requires no treatment. Instead, periodic observation and re-evaluation by a foot specialist or podiatrist should suffice.

Otherwise, treatment for the milder cases of flatfoot generally begins with supportive shoes, such as high tops, in conjunction with an in-shoe insert like arch padding. A more severe or painful deformity may require greater control and restriction of the foot’s abnormal motion through functional foot orthotics. Functional foot orthotics are special devices that stop the arch from flattening out and the heel bone from rolling while the child is standing, walking and running, thus reducing the symptoms while greatly improving the appearance and function of the foot.

Self-Care at Home

Calf muscle stretching exercises are commonly prescribed for children with tight calf muscles or shortened Achilles tendon since either can worsen both the symptoms and deformity with time. Exercises twice a day to stretch those muscles and the tendon will help speed up the foot’s natural straightening process. The exercises include:

  • In kneeling position, point your toes out behind and gently sit back on the heels, pressing the tops of the feet toward the ground.

  • Stand at an arm’s length from the wall. Place your hands on the wall, keep the feet and knees straight, then lean forward as far as possible.

  • Standing with your feet flat, bend the knees forward as far as possible while keeping the heels on the floor.

  • Over-the-counter arch supports can help relieve the pain caused by a flatfoot. They won’t cure the condition, but will often reduce the symptoms in the meantime.

  • Rest from activities that aggravate the child’s condition may be in order until his/her feet are feeling better.

  • If the child’s overweight, losing weight should put less stress on the feet and avoid further deformity.

Professional Treatments

If you suspect your child has a severe case of pediatric flatfoot or does not appear to be growing out of the condition, see a podiatrist as soon as possible, preferably before age three, for evaluation and, if necessary, treatment. The treatment for flatfoot typically becomes less effective and more complicated after age three.

Non-surgical approaches to treat the symptoms of a pediatric flatfoot include:

Activity modifications. Curtail or decrease all of the child’s activities that bring pain, while avoiding prolonged walking or standing.

Orthotic devices, the gold standard for treating pediatric flatfoot. Orthotics are shoe inserts that correct the alignment of the joints, ligaments and tendons of the foot to restore proper biomechanics. These are custom-made and designed to address each child’s specific foot structure and associated problems. They don’t cure the problem but maintain the child’s feet in proper position long enough for them to outgrow the condition, or at the very least keep the deformity from becoming worse.

Physical therapy. Stretching exercises supervised by a foot-and-ankle surgeon or a physical therapist to provide relief.

Shoe modification. The podiatrist can advise you on footwear and changes beneficial to a child with flatfoot.

Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may help reduce pain and inflammation.

Surgical Treatments

In rare cases, surgery is necessary to relieve the symptoms and improve foot function when the condition fails to respond to non-surgical options. It is done only for those children with the most severe deformities. Regardless, you should always seek a second option when considering surgery on your child’s foot.

A common procedure for pediatric flatfoot is the subtalar arthrodesis, or “implantable orthotic.” Taking only seven minutes to perform, the procedure placed an implant in the rear part of the foot through a tiny incision. The implant presents an immediate arch that enables the child to bear weight immediately and seldom needs removal. This is done for children with intolerable pain in the arch or a completely collapsed arch that will cause arthritic conditions when they get older.

How to Prevent a Pediatric Flatfoot/Talipes Calcaneovalgus?

The best prevention is to have the feet of a child showing the characteristics and symptoms of the condition examined before he/she is three years old. The reason is that the young feet are still largely made of soft cartilage with the very little bone present, and the exertion from moving with a flatfoot deformity can cause permanent changes to the bones and joints well into adulthood.

Even if there’s no conclusive sign of pediatric flatfoot, it is still sensible to follow most of the measures given in Self-Care at Home: Cut back or stop activities that caused pain in the child’s foot, stretch the calf muscles and Achilles tendon regularly, and eat healthy to prevent overweight.

Pigeon Toe/In Toe

What is a Pigeon Toe/In Toe?

Look down at your feet. Are they pointing straight or outward? If not and they’re pointing inward, the condition is called metatarsus varus, or pigeon toe and in-toeing in common terms.

Although in-toe gait — walking with inwardly turned feet — is a relatively harmless variation in how the legs and feet line up, it is a very common condition among young children and sometimes even adults. Babies of 8-15 months of age have a natural tendency to turn their legs in when they begin standing, and coupled with the fact that the bony foot structures are mostly soft cartilages (tissue between the joints and bones) at the time, the pressure on their feet can cause the toes to point inward. Fortunately, in-toeing in children is seldom more than growth and developmental stage and usually corrects itself naturally without medical or surgical treatment, as the child’s foot completes the gradual growing process to reach its final structure.

If a person is pigeon-toed, it does not mean something’s wrong with the feet; it just tells of the way the toes point when the person walks. The condition normally does not lead to serious problems nor cause arthritis or clumsiness, even if it never goes away.

Children with in-toeing sometimes have trouble getting shoes that fit, because the curve of their feet, which might make parents consider treatment for their child. Parents may also complain about their child frequently tripping over his or feet and runs in a funny or awkward fashion; such a condition can be evaluated to determine the level (foot, knee, hip) of relevance.

In a rare few children, the condition doesn’t improve on its own and must be treated. The severe cases are considered a form of clubfoot. In some cases, the children have a severe twist in the leg bone (tibia) or thigh bone (femur) that might bother them because it looks ugly — a problem that may be correctable only through surgery.

What Causes a Pigeon Toe/In Toe?

When it’s not due to simple muscle weakness, there are three main theories for pigeon toe. The first starts at the mother’s womb, suggesting that the infant’s legs are usually curled up in the cramped space as it grows, which causes a curvature in the feet as they are pressed into this position inside the uterus.

Second, after a child’s birth, the feet may appear flat but becoming more normal as the baby begins to walk. But if the contorting strain on the hips and legs is severe enough, those feet won’t correct themselves and will produce in-toe gaiting. The resulting twisted shin bone is the most common cause for children under 2 years old (and even with that the knees still point straight ahead). This condition usually improves when the baby starts to stand and walk, though it may take another 6 to 12 months to vanish completely.

Third, pigeon toes in girls over 2 years of age can most often be traced to a hip that turns in, which causes the thigh bone to twist. When the thigh bone twists, the knees, and toes point in. This condition usually goes away by itself, but the thigh bone may take 1 to 3 years to straighten.

Who Gets a Pigeon Toe/In Toe?

Pigeon toe is most common in infants and children under two years of age when the bone structure is still forming and the cartilages are soft enough to be affected by both internal and external pressure. Therefore, it becomes rarer as a body develops with age and corrects the minor flaws naturally. Still, a severe case that was not treated while the person was a child will last into adulthood.

Are There Different Types of a Pigeon Toe/In Toe?

Metatarsus adductus is a common foot deformity noted at birth that causes the front half of the foot (or forefoot) to turn inward — something the parents may notice this while a child is still a baby. In 9 out of 10 children with this problem, the feet straighten as the children grow up.

Internal tibial torsion is a condition in early childhood in which the tibia (leg bone) is twisted inward, causing the child to in-toe as hes/she walks. This is a very common condition and considered normal in babies as well as toddlers taking their first steps. In some children, the twist doesn’t unravel enough to point the feet straight ahead or outward, so these children are still in-toe when they begin walking. Nevertheless, walking often resolves it completely by the time a child reaches 18-24 months in age.

Femoral anteversion is an inward twist in the thigh bone. “Anteversion” literally means “leaning forward,” so this is a condition in which the neck of the thigh bone leans forward with respect to the rest of it, causing the knee and foot on the affected side to turn toward the midline of the body. Because some degree of rotation of the thigh bone is always present as kids grow, this is considered abnormal only when the twist is significantly more inward than an average kid of the same age. In fact, all babies are born with some such inward twist. This type of in-toeing normally appears in children between 2-4 years of age, after they begin walking. It can get worse during early childhood, but frequently the feet will straighten or point outward by the time a child reaches 6-8 years of age.

What are the Symptoms of a Pigeon Toe/In Toe?

The most obvious sign is, of course, the toes pointing inward when walking. It’s more noticeable when a child begins school.

When standing, an in-toed child’s kneecaps can appear to point in or squint toward each other, and the feet can seem asymmetrical (one side worse than the other). This may become more conspicuous at the end of the day when the child is tired.

As well, the child seems awkward when running with feet turning excessively inward, or prone to tripping and falling even on flat surfaces or when no obstacles are present.

Children with a twisted thigh bone often sit with their legs crossed or otherwise like to sit in a “W” position. The best way to treat this is to have the child sit in a chair with their legs uncrossed, though this often cannot be done until they are school age.

The crease of skin on the inside of the arch, a foot shaped like a “C” when viewed from the sole, and the front half of a foot is turned in relative to the back half of the foot are all symptoms pointing to metatarsus adductus.

How do You Diagnose a Pigeon Toe/In Toe?

Observing the patient when he/she is sitting, standing and walking is important. Seeing the position of the feet, knees, and kneecaps in these situations can give you a basic idea of whether a child has pigeon toe, as well as the possible type and severity of the condition. A thorough clinical examination, and in rare cases with x-rays and CT scans, may be necessary, especially if there is asymmetry of motion between the right and left hip (as it can indicate a misalignment of the hip joint).

How do You Treat a Pigeon Toe/In Toe?

Treatment for pigeon-toed feet is almost never required since most of the conditions are self-correcting during childhood. Time is typically the sole remedy needed, though it may take several years before an in-toed foot is straight. Only in the very few cases when it doesn’t get better on its own that you should seek treatment.

Self-Care at Home

If your child walks with his/her feet turned in, there are simple measures you can take to stop the condition from getting worse, such as positioning the child’s feet when he/she is sleeping so they are pointing outward, and encouraging the child to sit Indian style rather than on his/her knees or feet and forming a W in that position. Keeping the child from crossing his/her legs will help, too.

For very mild pigeon toes, you can ask a podiatrist to show you how to rub the outside of the foot to help straighten it. Some children may need to wear special shoes and braces, which is usually done before they reach 12 months of age.

If a pigeon toe is spotted early enough, non-clinical treatments include stretching exercises and even special bars to align the feet and lower legs. Ballet has been used to correct mild cases, and dance exercises can help to bend the legs outward.

Regardless, it is important to remember that many “in-toe” deformities correct themselves, often by a child’s eighth birthday. Knowing this will help you explain it to the child who may be depressed, frustrated, or even angry because of the way his/her feet look and the “funny” way he/she walks. The condition is very common and, chances are, the child will “grow” out of it soon enough. However, if you are concerned about a persistent condition or in-toe gait pattern, consult your podiatrist at the earliest opportunity.

Professional Treatments

For most cases, advice on how to adjust and improve the child’s knee and foot development from a podiatrist may be all that is necessary.

If the foot is rigid and cannot be straightened, the condition may necessitate putting casts on the feet and lower legs. A child who is tripping and falling or has an excessively turned-in posture will also benefit from a cast that goes above the knee for 2-6 weeks, followed by night splinting after the cast’s removal to maintain the correction.

The podiatrist may prescribe orthotics and braces to help move the foot toward external rotation when walking.

Surgical Treatments

Surgery is rarely performed unless the deformity is excessive enough to cause constant tripping and fall and there is a genuine concern over appearance. In a small number of children, the inward twist in the thigh bone is severe and doesn’t go away, so surgery may be necessary to cut the bones and turn (rotate) them outward to point the feet straight. The procedure is usually considered only when the children are at least 10 years or older.

How to Prevent a Pigeon Toe/In Toe?

Because a pigeon toe is something you are born with, you really cannot prevent the problem from occurring. However, applying the proper home or professional care will speed up the corrective process.

Calcaneal Apophysitis

What is a Calcaneal Apophysitis?

Calcaneal apophysitis is a painful inflammation of the growth plate (apophysis) at the back of the heel bone (calcaneus), where the Achilles tendon inserts. It normally affects children between 7 and 15 years of age, because the calcaneus is not fully developed until a child is at least 14 years old. Since the apophysis from which new bones grow is made up of cartilage and is softer than mature bone, the child is more susceptible to injury to that part of the body. Therefore, when impact or disturbance is exerted repeatedly on the growth plate and heel bone through running, jumping, climbing, etc., the stress can easily produce trauma that leads to pain. This is especially true for young boys and girls who are physically active and participate in sports.

Calcaneal apophysitis also called Sever’s disease — named for JW Sever who characterized it in 1912 — though it is not a true “disease” at all. It is, however, the most common cause of heel pain in children and can occur in one or both feet. It differs from the adult variety in that while heel pain in adults usually subsides after some walking, calcaneal apophysitis generally doesn’t get better in this manner but just the opposite: walking typically makes the pain worse!

Sever’s disease is one of several different orthopedic diseases of the joint that occur in children (or “osteochondroses”), and is related to the Osgood-Schlatter disease that affects the knee rather than heel.

What Causes a Calcaneal Apophysitis?

Overuse and stress on the heel bone through participation in sports is a primary cause of the calcaneal apophysitis. The repetitive pressure and exertion while playing soccer or basketball, or simply excessive running like a kid typically does will put strain on the apophysis, possibly causing minor trauma or tear of the cartilage. It can be almost epidemic at the start of certain sports seasons, especially if the game is played on a hard surface during winter.

Heavier or obese children are believed to be at greater risk for developing calcaneal apophysitis due to the greater weight bearing down on the heels and growth plates that causes excessive traction on the still-growing bones and tendons. Biomechanical problems such as a high-arched foot or flatfoot can also be a contributing factor.

Another potential cause is a tight Achilles tendon or tight calf muscles. Because running and jumping generate a large amount of pressure on the heels, both are risk factors for they increase the tension of the growth center. Wearing shoes with poor heel padding or poor arch support can make the situation worse or even originate the condition in the first place.

For unknown reasons, some children can be more prone than others to calcaneal apophysitis. It does occur more frequently in children who pronate, and in more than half of the cases (approximately 60%) the condition affects both heels.

Who Gets a Calcaneal Apophysitis?

The condition is seen only in boys and girls from 7 to 15 years old and does not affect adults, since the two bony regions around the heel and apophysis fuse together around age 16 to complete the growth process.

Among the age range, calcaneal apophysitis is most prevalent in physically active boys and girls between 10 and 12 years old. Given a developing heel growth plate is sensitive to the repetitive pounding from running and jumping on hard surfaces, it is not surprisingly, then, that children and adolescents involved in track, gymnastics, soccer, or basketball are particularly vulnerable to calcaneal apophysitis.

What are the Symptoms of a Calcaneal Apophysitis?

Pain is usually felt at the back and side of the heel bone, and sometimes in the back or bottom of the heel. Squeezing the sides of the heel bone is often painful. In more severe cases, the child may be limping or walking on toes to avoid putting pressure on the affected heel(s). The child is usually relieved of the pain when not active, only to have it return when re-engaging in a sports activity, and have difficulty running, jumping, or climbing — all of which worsen the symptoms!

Heel pain in children can often return after it has been treated because the heel bone is still growing. Recurrence of heel pain may be a sign of calcaneal apophysitis.

How do You Diagnose a Calcaneal Apophysitis?

Doctors will diagnose a calcaneal apophysitis based on physical examination of the lower leg, ankle and foot, along with a review of the child’s medical history, recent activities, and symptoms. To rule out other more serious conditions, a doctor may order x-rays that are a normal procedure for diagnosing Sever’s disease.

How do You Treat a Calcaneal Apophysitis?

Calcaneal apophysitis has no known long-term complications and is self-limiting; that is, it will go away when the two parts of bony growth eventually join together in a natural process (occurring around 16 years of age). Until then, however, it can be very painful and can restrict a child’s activities while waiting for it to subside, so treatment to relieve pain is often advised.

Management of the condition by a health professional is commonly recommended. There are a few very rare problems that may be causing the pain, so a correct diagnosis is important.

Self-Care at Home

The following is suggested for a child with calcaneal apophysitis:

Cut back on sporting activities. It’s not necessary to stop completely, just reduce the time and intensity until symptoms improve. Athletic strap or tape is sometimes used during activity to limit the ankle-joint range of motion. If the condition has been present for a while, longer or even total break may be in order later.

Use a soft, cushioning heel raise to reduce the pull from the calf muscles on the growth plate, while increasing the absorption of a shock to the heels.

Stretch the hamstring and calf muscles with simple exercises that do not cause pain in the apophysis, 2-3 times a day.

Placing an ice pack on the heel(s) after activity for 20 minutes can be very conducive to recovery as it reduces pain and inflammation. This should be repeated 2-3 times daily, and as often as every hour when experiencing soreness.

Always have comfortable footwear on to minimize impact with the surface.

Anti-inflammatory medication may be needed to alleviate intense pain or relieve symptoms not responding to the measures above.

The goal is to return your child to the sport or activity as soon and safely as possible. If the child returns to activities too soon or plays with pain, the injury can worsen, thus leading to chronic pain and difficulty with sports. Because everyone recovers from injury at a different rate, how soon the condition resolves will determine the time of the child’s return to activity, not how long it has been since the condition first arose. Generally, the longer a child has had symptoms before starting treatment, the longer it will take for the injury to heal. If the pain recurs upon resuming activity, the child should rest, ice, and stretch until the pain is gone before trying to return again.

Topical Professional Treatments

A doctor may choose one or more of the following options to treat calcaneal apophysitis, most of which mirror home treatments:

  • Reduce or stop any activity that causes pain.

  • Temporary shoe inserts, gel heel cups, or custom orthotic devices to provide support for the heel.

  • Nonsterioidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, to control the pain and inflammation.

  • Stretching or physical therapy modalities to promote healing of the inflamed issue.

  • In some severe cases of calcaneal apophysitis, the foot and ankle may require immobilization in a cast for 2-6 weeks, affording it a good chance to heal.

  • Surgical Treatments

  • Surgical treatments are not used or necessary to treat calcaneal apophysitis.

  • How to Prevent a Calcaneal Apophysitis?

  • A child can reduce the chance of developing a calcaneal apophysitis by:

  • Avoiding obesity.

  • Choosing well-constructed, supportive shoes appropriate for the activity, while avoiding or limiting the wearing of athletic shoes with cleats.

  • Avoiding activity beyond the child’s ability.

  • Wearing supportive, well-padded, shock-absorbing footwear that fit properly.

Performing proper warm-up prior to any activity. Ten minutes of light jogging, cycling, or calisthenics beforehand will increase circulation to cold muscles, making them more pliable so they will put less stress and tension on the growth plates.

Never playing through pain. Pain is a sign of overuse, stress, or injury. Rest is necessary to give body parts time to recuperate and heal.

  • Stretch tight calf muscles several times a day. It is better to stretch after exercise. Hold each stretch for 30 seconds without bouncing. Some of the calf-stretching exercises a child can do include:

  • Kiss the Wall. Standing about two feet from a wall. Flex the left foot and place it against the bottom of a wall. Keep your back tall and straight. Then, lean forward from the hips as if you were trying to kiss the wall. Repeat with the other leg.

  • Standing Calf Stretch. Facing a wall, put hands against the wall at about eye level. Put one foot in front and keep the forward knee bent. With the back knee straight, push the heel of the back leg down on the floor and slowly lean into the wall until you can feel the back calf muscle stretch. Repeat with the back knee bent. Then, repeat both stretches with the other leg in front.

  • Towel Stretch. Sit on the floor with the affect leg stretched out. Loop a towel around the ball of that foot and pull the towel toward the body. Keep the knee straight. Repeat for the other leg.

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