Children’s feet – some practical pointers for parents

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Children’s Feet – some practical Pointers for Parents

Clubfeet are serious

The most significant congenital foot problem is a clubfoot (aka talipes equino varus) which affects approximately 1:1000 births, mostly in little boys, and mostly affecting both feet. 70-80% of children born with a clubfoot are otherwise healthy, so good treatment means they can usually walk and run about like everyone else, even if their feet (or foot) may look a little different sometimes. The non-surgical Ponseti method is regarded globally as the ‘gold standard’ treatment, as it gives the best results by far, and can be a ‘labour of love’ for parents as the foot is gradually corrected over some weeks, with a maintenance brace then worn during sleeps for a few years following to avoid clubfoot ‘springing back’. It should be all over by school age. A lucky few with clubfeet are remarkably flexible, and correct more easily.

Clubfoot has genetic markers (chromosomes 2, 9, 12, 17 have been implicated) but it varies, and some are definitely more responsive to treatment than others. But what used to be a disabling deformity for life, is now well-managed by clinicians who use the Ponseti method.

Most (approx. 80%) of the children born with clubfoot deformity live in developing countries where only 15-20% can access treatment. There are some great aid programs improving this, including ‘Walk for Life’ in Bangladesh, where over 24,500 children have been treated since 2009 ( https://www.facebook.com/profile.php?id=554201651456511&ref=br_rs ).

 

Other Foot conditions

There are other foot problems that children can be born with, but none as usually as serious as clubfoot. The main ones include metatarsus varus/adductus (‘banana’ foot), calcaneo-valgus (foot turned ‘up and out’), vertical talus (super flat – convex and stiff/rigid flatfoot). Occasionally, children are born with differently formed feet – webbed toes, more or less than 5 toes, bones joined together, or odd looking nails. Some of these conditions require treatment, and many milder cases do not. A baseline assessment can be helpful to establish whether a condition is mild / moderate / severe, and it may also be useful to monitor with growth to see whether things are getting better or worse, and then managing accordingly.

 

Flatfeet

Generally, babies feet look fairly flat to begin with, and this is because the feet have substantial adipose padding, soft forming bones, and haven’t been elongated and stretched out by standing and walking. Young children are expected to have flat looking feet, which generally reduces by age 10 years. The left and right feet should look similar, and the feet should not hurt. Flat feet create far too much worry overall, and many unnecessary visits to doctors.

 

A New Practical Guideline for Flatfeet

A new guideline for clinicians has been developed to better sort out the cases of flat feet  – also knock knees, bow legs, and in-toeing walking (pigeon toe). The 3QQ (or 3 quick questions) is helpful for parents as well as it gives general guidance as to what foot, knee, walking patterns are ok at what ages. If parents have any further doubts, then a paediatric focused Podiatrist or GP can assess further, and use the full version of the 3QQ (Mitigating clinician and community concerns about children flatfeet, intoeing gait, knock knees or bow legs. J Paediatr Child Health 2017;53:1050–3. doi:10.1111/jpc.13761).

 

The 3QQ reference chart for parents

3QQ 3 Quick Questions	Intoe	Knock-knees	Flatfeet
1. Does it hurt?	Yes = problem	Yes = problem	Yes = problem
2. Is it asymmetrical?	Yes = investigate further	Yes = investigate further	Yes = investigate further
3. Probably ok if age is: (developmental age range)	< 6 years	> 2 years	< 10 years

Note: Indications for further investigation, medical consultation include:

• Intoeing gait: trip and fall > 5 times/day, everyday
• Knock knees: > 10 cm between ankle malleoli
• Bow legs: > 2 years *
• Flatfeet: rigid, arch does not change shape from standing to sitting

[The parent version of the 3QQ, is adapted from: Mitigating clinician and community concerns about children flatfeet, intoeing gait, knock knees or bow legs. J Paediatr Child Health 2017;53:1050–3. doi:10.1111/jpc.13761]

Podiatrists have access to age expected data for children’s foot posture, and this can be provided as part of a consultation, so that you know that your child’s feet are regular or less regular for their age [See: https://angelaevanspodiatrists.com.au/evidence-essentials-blog-7-may-2019/ ].

 

On the Move..

Babies start to move with amazing adherence to expected milestone ranges, and the three focus movement milestones are sitting, crawling, and walking. Children may begin to walk as early as 10 months (look out!), whilst most start just after 12-13 months, and others by 15-16 months – all are considered to fall within usual range. There is mostly a reason for children not walking by 18 months, and this can be a family trait too. Very flexible joints, softer muscles (low muscle tone) are not infrequent findings in children whose walking onset is delayed. Treatment for these children can be very effective, and it is always important to gain a full clinical picture, which often involves a Paediatrician to set up a wider management plan.

Babies and infants are very active on the floor in the first year of their lives, and this is the best environment for them. What looks like rolling around and being very cute (which it is!) is really developmental ‘gym work’, where babies learn positioning, feel, movements and gain strength, balance and importantly interest in being part of their place and space. Floor play is best, and much preferred for developing legs, feet, hips and backs over devices that swing, bounce, sit, jump infants about – their physical structure are not ready for those forces, and its generally better to let them work at their own strength and movement skills.

If an infant is later than usual to walks (after 16-18 months), then it’s worth a check up, to identify the reason, and usually then set up a treatment plan to get them moving. Physiotherapists are actively involved in this area, and your child’s team (Physio, GP, Paediatrician, Podiatrist etc) coordinate and contribute for best results.

 

First Shoes

When development is going along usually, the first 12 months of age are usually a shoe-free time. Footwear’s basic function is for protection, so children don’t require this until they are going outside and need to avoid prickles, hot pavers, stubbing their toes etc. First shoes, for children whose development is on track, need to be light-weight, flexible, and fairly thin soled so that the child when new to being upright on their feet can still ‘feel’ the ground beneath them to assist balance. Generally the need for first shoes can be put off until independent walking has been established for a month or two. Socks as well as shoes need to fit the child’s foot and also allow for the rapid growth and elongation that occurs in the toddler years. At this age, shoe changes for a bigger size may be every 3-4 months – mercifully, this does slow a little from school age onwards. A good shoe fitter for this age is such a bonus, as it’s not so easy to know where the end of a little foot is in a covered shoe; sandals are much easier.

A couple of tips for shoe fitting are to trace the child’s foot when they’re standing, cut out the traced ‘foot print’ and make sure it slides inside the shoes easily, with allowance for growth. New shoes can take a while to adjust to, so short periods when children are not tired, is initially advisable. Generally, it’s good and practical to have shoes off inside, to get the foot muscles active and strengthening, and use shoes for outside, when protection is needed. This principle will modify when children require footwear/support to help their walking stability, and the Podiatrist involved will guide you about footwear use as needed. This is not uncommon when children have delayed walking, and the full clinical picture needs to be assessed, as late walkers may need help in some other areas too.

 

Summary points

• Flatfeet are the norm in early childhood, and expected to reduce with age.
• Shoes are generally not needed until walking for 1-2 months, and barefoot inside makes foot muscles work and strengthen
• Little feet grow fast – shoes may only for for 3-4 months – don’t forget to upsize socks with growth too!
• As many as 30% of children aged up to 6 years may intoe as part of development
• Bowlegs are expected under age 2 years, but should be checked if present at an older age.
• Knock knees are expected from about age 3 years, and reduce/remain with variation after this age.
• Left and right feet and legs should look fairly similar
• Foot pain, and leg pain, are unusual complaints in pre-schoolers especially, and needs to be assessed by either a GP or Podiatrist who sees young children.
• Limping, falling over more not less with age, sore joints or bony ‘bumps’ are not normal and need to be seen by either a GP or Podiatrist.
• Walking as a milestone, usually happens between ages 10-16 months. When children are not walking at 18 months, further assessment is indicated, and intervention frequently involves a health care team.
• As parents, if something looks odd and is still worrying you after reading this article, then a check-up is wise.