When something goes wrong with children's feet
When our children were jumping barefoot through the garden together a few weeks ago, my friend pointed out to me that my five-year-old son's foot looked different to her child's. His big toe and the toe next to it crossed a little. His big toe and the toe next to it cross a little. It is more pronounced on the left foot.
I wondered whether the overlapping toes might indicate hallux valgus. This is a deformity of the big toe where the ball of the foot curves more and more to one side. I have also been affected by this since my youth.
Frequent phenomenon
Foot deformities are widespread - especially in childhood. The most common is fallen arches, as Hanspeter Huber, Head of Paediatric Orthopaedics at Winterthur Cantonal Hospital, explains. «50 to 90 per cent of children are affected in the first few years of life. In later adolescence it is still around 20 per cent, and in adulthood only 5 to 10 per cent.»
Other typical foot deformities that frequently occur in children and adolescents are flat feet, clubfoot, sickle foot and heel foot. It is difficult to put a figure on how many children in Switzerland are generally affected by foot deformities. However, it is likely that at least every second family deals with this issue at some point.
From buckling and flat feet
In common parlance, the terms «flat foot» and «fallen arches» are often confused or used interchangeably, even though they refer to different things. «The flat foot is a flexible foot with a flattened arch, in which the heel also bends outwards under load,» says Hanspeter Huber. «The flat foot is also flat, but significantly less flexible than the flat foot. Due to a shortening of the muscles or an adhesion of bones in the hindfoot, it cannot be easily brought into a normal position, either actively or passively.»
A certain genetic component is almost always involved.
Hanspeter Huber, paediatric orthopaedist
Splayfoot is also common in adolescents. «It is characterised by the fact that the metatarsal bones spread apart and the forefoot is wider. This can be favoured by a weakness in the connective tissue,» says Huber. «However, splayfoot is more of a normal variation and not a disease.» Complaints usually only arise from wearing shoes that are too narrow. «I see time and again that many young people want to wear trendy, narrow-cut trainers or sneakers, regardless of whether they fit or not,» says the orthopaedist. «The peer pressure is enormous.»
Trainers that are too narrow
Shoes that are too narrow, tapered and those with a higher heel can lead to the development of hallux valgus in adulthood, and this is even more the case with an existing splayfoot. Obesity is also a common cause of foot pain and can favour the development of foot deformities, according to Hanspeter Huber. There are often several factors that come together.
However, the expert also emphasises: «A certain genetic component is almost always involved.» Clubfoot, one of the classic foot deformities in infants, can be recognised as early as the 20th to 24th week of pregnancy using ultrasound examinations.
Worries are often unjustified
The flexible deformity of the flat foot is only visible after the child starts standing and walking and occurs as part of normal development. «The reasons for this are an increased fat pad on the sole of the foot, excessive mobility of the connective tissue, the increased internal rotation of the thigh and lower leg that still exists in infancy and possibly muscular immaturity,» says Huber. In most cases, the arch of the foot straightens itself as the child grows. In some cases, however, the calf muscles can shorten, which in turn can make spontaneous correction more difficult and possibly cause pain.
Paediatric orthopaedist Hanspeter Huber notices that parents are very quick to worry, for example if the foot buckles slightly when walking or the soles are crooked. But Huber can reassure parents: «You don't need to do anything about fallen arches as long as the child is not in pain.»
Crooked shoes are not an indication that the child has a foot deformity at all, although looking at the shoes gives this impression. However, if children and adolescents have pain when walking, they should see a paediatrician and have it checked out. «They can usually give the all-clear first,» says Huber.
So did my son's paediatrician. During the check-up, she immediately noticed that his toes were slightly crossed. I asked her whether this could be a sign of hallux valgus. The doctor said that it was still too early to say. For the time being, it would be enough to continue observing the development of his feet and make sure that his toes had enough room in his shoes.
Insoles only for pain
Hanspeter Huber says: «In cases where further clarification is required, a referral is made to a paediatric orthopaedist.» They will then clarify whether and how the foot needs to be treated. «Insoles used to be prescribed very quickly,» says the expert. «However, various medical studies have shown that these do not have a relevant positive effect on straightening the foot - as in the case of flat feet. Insoles are therefore usually only prescribed for pain. In this case, they can provide relief.»
Walking barefoot is very healthy for the feet. All muscles are activated.
Melanie Hoffmann, physiotherapist
Children with severe hallux valgus are often prescribed a night splint. This presses the big toe in the right direction. Due to the significant growth of the foot in childhood, the splint can still counteract the deformity slightly. In adolescents and adults, wearing a splint no longer makes much sense.
Physiotherapy as support
Physiotherapy is another option for treating foot misalignments and associated pain. Melanie Hoffmann works as a physiotherapist for babies and children in Zurich. On average, 15 to 20 per cent of her patients have foot misalignments. She confirms Hanspeter Huber's statements: «In infants, it's mostly club, sickle and hooked feet, and in toddlers and schoolchildren it's more likely to be flat feet.»
Hoffmann does exercises with the children that are specially adapted to the respective foot malposition. The exercises strengthen the muscles, reduce pain and counteract the misalignment. Even if you don't have any pain, you can still do your feet good with exercises.
«Walking barefoot is also very healthy for the feet,» says the physiotherapist, «the foot can move freely and has to adapt to different surfaces, so all the muscles are activated.» Uneven and varying surfaces such as sand, forest floor, mud, stones and soft soil are suitable for strengthening the muscles. «The foot and calf muscles have to help so that we can move, stand stably and keep our balance.»
Slight foot misalignments can be counteracted with appropriate exercises and lots of barefoot walking. However, there are complex deformities where exercises alone are not enough, such as clubfoot. «This deformity must be treated by an interdisciplinary team of specialists,» says Hoffmann.
Foot in plaster shortly after birth
Paediatric orthopaedist Hanspeter Huber also emphasises this. «A slight clubfoot posture can correct itself, but a «real» clubfoot needs to be treated orthopaedically just a few weeks after birth, using the so-called Ponseti method.» The foot is gently straightened and plastered. The plasters are changed every week so that the foot position can be gradually improved. After around four to eight weeks, the deformity can be corrected.
«In most cases, the severely shortened Achilles tendon then has to be lengthened through a small incision so that the foot can move sufficiently,» explains Huber. «But this is a minor procedure.» If the deformity occurs again in older children, it may make sense to perform an operation, says Huber. This involves moving the attachment of a foot lifter tendon further outwards from the inside of the foot so that the foot does not turn inwards again.
- Roll and massage the soles of the feet with a tennis ball, hedgehog ball or black roller ball. Then smooth out and mould the longitudinal and transverse arches with your hands.
- Stand on tiptoe on one leg. Make sure that the big toe remains on the floor and that the ankle joints do not bend outwards, but remain in line with the lower leg. This exercise should be performed with the knee joint extended and repeated around 15 to 25 times. Then it's the other foot's turn. Do this three times on each side.
- Walking on the outer edge of the foot.
- Walking on the heels.
- Gripping exercises with the feet: If you can manage it, stand on one leg and pick up small objects such as marbles, small bags of sand or similar from the floor with the other foot and place them in a small bucket on the other side of the standing leg so that the gripping foot has to cross over the standing leg. If standing is too difficult, you can also start sitting, for example on a large exercise ball. You can also try to grasp or hold flat objects, such as paper or coins, with your feet.
Source: Melanie Hoffmann, physiotherapist
When does surgery make sense?
Surgery can also be considered from the age of ten to twelve if the child has a pronounced flat foot with symptoms. «In what is known as arthrorisis, a screw is inserted into the heel bone to prevent the hindfoot bones from buckling in relation to each other,» explains the paediatric orthopaedic surgeon. As the bone continues to grow, this procedure can achieve a permanent correction of the foot position.
«Surgery before the age of ten is practically never advisable for a flat foot unless there is a very severe shortening of the calf muscles,» he says. And surgery can still be performed in later adolescence and adulthood if the extent of the symptoms is so restrictive that it justifies major surgery.
