Children's Foot and Ankle Problems

Many children’s foot and ankle problems are either variations of normal or are self-limiting. Where there is any doubt about the significance of a child’s foot or ankle problem, referral can be made to Orthotics for specialist assessment with onward discussion at our Multi-disciplinary meeting if required.

Intoeing is walking with a foot or usually both feet pointing inward (an internal foot progression angle). Most resolve by age of 6-8. Persisting intoeing has not been linked with any long term problems but infrequently some cases may benefit from surgery. Intoeing may be due to Internal Tibial Torsion, Femoral Neck Anteversion or Metatarsus Adductus. Most cases resolve by the age of 6-8. Those which persist and cause concern should have physiotherapy assessment +/- onward referral.

Many infants walk on their tip toes after learning to walk. After this persistent tip toe walking is fairly common and is seen in around 10-20% of children, with most cases resolving by around the age of three. A small number continue to tip toe walk after this age. Most cases are habitual with no underlying problem. Occasionally there may be short or tight calf muscle whilst rarely there may be an underlying neuromuscular or developmental condition.
Tip toe walkers after the age of three should be referred to Children’s Physiotherapy for assessment and calf / Achilles stretches. Occasionally, onward referral to Orthopaedics may be required for consideration of tendon lengthening if physio (which may include serial casting or splintage) fails.

Idiopathic or physiologic flat feet with loss of contour of the medial arch, often with a heel which goes into valgus alignment on weight bearing, is a common variant of normal (1 in 5 adults). The arch should reform on passive dorsiflexion of the toe and on standing on tip toes. It is due to laxity of the supporting ligaments and it may run in families. The use of orthoses is controversial and in most cases is not indicated unless an associated ache or severe footwear issues.
Painful rigid flat foot may have an underlying abnormal connection between the tarsal bones (Tarsal Coalition) which may benefit from surgery and should be referred for assessment and investigation.

Cavovarus feet should always be referred to our Children’s Orthopaedic Service for assessment including neurologic examination. They often require MRI investigation and paediatric neurology input and most require surgery.

Juvenile or adolescent hallux valgus is often bilateral and familial. Hypermobility and flat feet are often also present. Pain is typically not a main feature – patients tend to complain of the cosmetic appearance and/or difficulty with footwear.
Surgical realignment has a high recurrence rate (over 50%), complications can be significant and overcorrection is poorly tolerated. Patients should be referred to Orthotics for assessment and advice on footwear with onward referral if required. Surgery is typically only performed after skeletal maturity (16 years in girls and 18 in boys).