Review for the generalist: evaluation of pediatric foot and ankle pain

The F-words relating to symptomatic flexible flat feet: A scoping review

Flexible flat feet are one of the most common musculoskeletal concerns presenting to paediatric health services, despite this being an expected finding in children under 10 years and only requiring management when symptoms are associated. Understanding which symptoms are associated with symptomatic presentations of flexible flat foot in children will provide clarity in identifying those that require further assessment and/or intervention. A scoping review of the literature was conducted to gather all known symptoms related to symptomatic flexible flat foot in the child. Data was mapped using the 'F-words' framework, a child friendly, six-item tool based on the International Classification of Functioning, Disability and Health Framework 11 (ICF-11). This review identified 42 individual symptoms relative to symptomatic presentations of flexible flat foot, which were allocated into five of the six 'F-words' categories (fitness, functioning, friends, family and future). Of these, pain was the most reported symptom, identified in 124 (of 133) included citations, followed by symptoms associated with reduced lower limb function (altered gait patterns, reduced balance and stability and increased tripping), fatigue and reduced participation. Other less frequently reported symptoms include callus formation, night pain and cramps. When present, these symptoms may occur independently or may co-exist at the same time. No symptoms were allocated to the fun category of the 'F-words'. A multitude of symptoms are reportedly associated with symptomatic flexible flatfoot in the child, with no discernible pattern or coherence noted. Further research should examine development and progression of symptoms and seek to better understand causality of relationship between symptoms and foot posture.

Management of pediatric ankle fractures: comparison of biodegradable PLGA implants with traditional metal screws

Introduction

The relevance of biodegradable implants has gained more importance in modern clinical practice. The study aimed to evaluate the effects and outcomes of ankle fracture treatment with absorbable implants compared to metal screws. These implants are made from poly l-lactic-co-glycolic acid (PLGA), however, there are several other materials available on the market.

Methods

In a retrospective review, a total of 128 patients were under observation, with distal tibial fracture types ranging from Salter-Harris II-IV. In the absorbable group, patients were treated with the implants (n = 76). The metal group included patients treated with titanium or steel screws (n = 52). The extremities were placed in a cast for six weeks after surgery and were utilized for another 6-8 weeks. Patients were followed up for 12-30 months and were evaluated accordingly. The authors examined several aspects such as age, gender, open or closed repair, mechanism of injury, length of hospitalization, type of fracture, time of recovery, and complications.

Results

There were no statistically significant differences between the groups regarding demographic qualities, such as age, type of fracture, side of injury, and length of cast application (p > 0.05 in all cases). Out of 76 patients in the PLGA group, only two presented with complications, so reoperation took place. The rest healed without complications or refractures. Two of those treated with metal screws (n = 52) had minor, and four had major complications with reoperation.

Discussion

In pediatric cases, PLGA implants may present excellent results for treating ankle fractures. They do not disturb the growth plate and do not require reoperation. For this reason, they reduce the burden on the patient and the healthcare provider while simultaneously decreasing the risk of complications, such as infections or problems due to general anesthesia.

Foot and ankle problems in children and young people: a population-based cohort study

The aim of this research was to describe the epidemiology, presentation and healthcare use in primary care for foot and ankle problems in children and young people (CYP) across England. We undertook a population-based cohort study using data from the Clinical Practice Research Datalink Aurum database, a database of anonymised electronic health records from general practices across England. Data was accessed for all CYP aged 0-18 years presenting to their general practitioner between January 2015 and December 2021 with a foot and/or ankle problem. Consultation rates were calculated and used to estimate numbers of consultations in an average practice. Hierarchical Poisson regression estimated relative rates of consultations across sociodemographic groups and logistic regression evaluated factors associated with repeat consultations. A total of 416,137 patients had 687,753 foot and ankle events, of which the majority were categorised as "musculoskeletal" (34%) and "unspecified pain" (21%). Rates peaked at 601 consultations per 10,000 patient-years among males aged 10-14 years in 2018. An average practice might observe 132 (95% CI 110 to 155) consultations annually. Odds for repeat consultations were higher among those with pre-existing diagnoses including juvenile arthritis (OR 1.73, 95% CI 1.48 to 2.03).    Conclusions: Consultations for foot and ankle problems were high among CYP, particularly males aged 10 to 14 years. These data can inform service provision to ensure CYP access appropriate health professionals for accurate diagnosis and treatment. What is Known: • Foot and ankle problems can have considerable impact on health-related quality of life in children and young people (CYP). • There is limited data describing the nature and frequency of foot and ankle problems in CYP. What is New: • Foot and ankle consultations were higher in English general practice among CYP aged 10 to 14 years compared to other age groups, and higher among males compared to females. • The high proportion of unspecified diagnoses and repeat consultations suggests there is need for greater integration between general practice and allied health professionals in community-based healthcare settings.

The Assessment of Ankle Range-of-Motion and Its Relationship with Overall Muscle Strength in a Cross-Section of Soccer Players

Soccer (football) practice can induce a limitation of ankle range of motion (ROM) that is a possible risk factor for injury and other negative consequences over time. The main objective of this research was to investigate the effects of soccer practice on ankle ROM throughout the entire period of a sports career of soccer players (SP). Furthermore, the relationship between ankle ROM and muscle strength in SP of different ages was studied. A total of 204 SP (range 6.7−45.1 years) and 87 controls (range: 7.5−45.2 years) matched for age, body mass index (BMI), and gender, were assessed. Ankle ROM in both plantar flexion (APF) and dorsiflexion (ADF) in addition to handgrip strength (HGS) were evaluated using an inclinometer and the Jamar hydraulic hand dynamometer, respectively. The comparison between SP and control groups showed a significant reduction in ankle ROM of both APF (26.3 ± 7.2° vs. 32.6 ± 7.4°; d = −0.90; p < 0.001) and ADF (95.5 ± 15.6° vs. 105.5 ± 15.8°; d = −0.66; p < 0.001). In SP, the results of the ANOVAs test indicate that age had a significant effect on ADF (F = 4.352, p = 0.038, partial eta-squared (ηp2) = 0.015) but not on APF (F = 0.430, p = 0.746, ηp2 = 0.001). Moreover, considering only the SP, a weak inverse correlation between ADF and HGS group ADF was found (rs = −0.27; p < 0.001). Factors such as the non-linear trend of growth in young SP could hinder the definition of the relationship between ankle ROM, age, and muscle strength. However, the appropriate consideration of age and muscle strength could facilitate the management of ankle ROM in PF of different ages.

Foot and Ankle Conventional Radiography in Juvenile Idiopathic Arthritis: Does It Still Matter?

Objectives:

The aim of this study was to evaluate the residual value of Conventional Radiography in children with arthralgia clinically suspected of Juvenile Idiopathic Arthritis (JIA).

Materials and Methods:

Three hundred seventy-two patients aged 1–18 years suspected of JIA were retrospectively reviewed. All patients had foot and ankle plain films performed in standard two projections: ankle in antero-posterior and lateral, and foot in antero-posterior and oblique. The cohort was divided into two groups: patients with confirmed JIA and non-JIA control group of children with foot and ankle arthralgia without diagnosis of inflammatory connective tissue disease. Radiographic findings in both groups were compared.

Results:

In 40% of JIA and 70% of non-JIA patients radiographs were normal. All radiographic findings were significantly more common in JIA than in non-JIA group (p = 0.000). Soft tissue swelling was the most frequent abnormality found in JIA patients (31, 51%) and only in 2.41% of non-JIA patients (p = 0.000). Osteoporosis and joint space narrowing were also significantly more common in JIA group (p = 0.000). The majority of imaging findings in non-JIA group were non-inflammatory abnormalities.

Conclusion:

Conventional radiography is an important tool in differential diagnosis of arthralgia of unknown etiology, as soft tissue swelling, osteoporosis and joint space narrowing are significantly more common in JIA patients as compared with patients without the diagnosis of inflammatory connective tissue disease. However, in case of high clinical suspicion of JIA and normal radiography, we recommend subsequent ultrasound (US) and/or MRI to allow early treatment.

The Effect of Customized and Silicon Insoles on Mid- and Hindfoot in Adult Flexible Pes Planovalgus

BACKGROUND

Flexible flat foot or pes planovalgus is a common foot deformity, and silicone and customized insole are commonly used as a non-operative treatment modality of flexible planovalgus. However, there are inadequate data and limited evidence available regarding the immediate effects of their use in midfoot and hindfoot of adults. The aim of this study is to quantify and compare the radiological parameters immediately on weightbearing with silicon and customized insoles and without them to assess the effect on midfoot and hindfoot of the flexible planovalgus in adults.

METHODS

A total number of 11 (8 females and 3 males) subjects with flexible pes planovalgus deformity without any other foot deformity were included in the study. Each patient was assessed three times in a random sequence without and with use of either silicon insoles or customized insole. The radiographic parameters without insole, with silicon insole, and with customized insole conditions were calculated using online available computer software Kinovea.

RESULTS

One-way ANOVA analysis was performed between groups (without insole, with silicone insole and with customized insole). The hindfoot parameters depicted that calcaneal inclination angle (CIA) was significant increased (P = 0.000) and talar declination angle (TDA) was significantly decreased (P = 0.003) only with the use of customized insole compared to without insole. The midfoot parameters depicted that the first metatarsal angle (FMA) and talonavicular coverage angle (TCA) were significantly lower with customized insole (P = 0.00) as compared to other two groups and significantly lower with silicone insole (P = 0.00) as compared to without insole group.

CONCLUSION

The results imply that the compressibility of the insole material affects the forefoot and hindfoot biomechanics differently. This study concludes that silicone insole affects only the midfoot which bears 45% of bodyweight and customized insole affects both midfoot and more importantly the hindfoot which bears 55% of bodyweight.

Bone stress injuries in the presence of tarsal coalition as a cause of hindfoot pain in adolescents: case series of 6 patients with literature review

OBJECTIVE

To highlight causal relationship between stress fracture in the presence of tarsal coalition and hindfoot pain in adolescents on magnetic resonance imaging (MRI).

MATERIAL AND METHODS

A retrospective review was performed of the clinical and MRI imaging findings of 6 adolescents referred for MRI to evaluate symptoms of hindfoot pain with possible tarsal coalition. MRI studies were systematically assessed for cause of hindfoot pain, types of tarsal coalition, patterns of stress fractures, bone marrow oedema and any other associated features.

RESULTS

All the 6 patients (4 male: 2 female) aged between 12 and 19 years developed insidious onset of hindfoot or midfoot pain over a period of weeks to months. On MRI, all 6 cases had features of fibrous tarsal coalition predominantly in the calcaneonavicular articulation (5 out of 6 patients). Associated stress fractures/response were in the posterior facet/body of the calcaneus (3), talar head (2), cuboid (1) and third metatarsal bone in one patient.

CONCLUSION

Stress fractures/response adjacent to tarsal coalition could be because of altered biomechanics and can be an unusual cause of hindfoot pain in adolescents. A high index of suspicion and complementary MRI findings is crucial to interpret this condition to direct appropriate patient management.

Plantar flexion, dorsiflexion, range of movement and hindfoot deviation are important determinants of foot function in children

PURPOSE

Paediatric foot surgery is often performed to restore anatomical shape or range of movement (ROM). The purpose of this study was to determine how foot morphology and ROM are associated with foot function in children aged five to 16 years of age.

METHODS

Participants included 89 patients with foot disorders and 58 healthy controls. In addition to measuring children's foot alignment and ankle ROM, children and parents completed the Oxford Ankle and Foot Questionnaire (OxAFQ).

RESULTS

Mean age was 10.3 years for patients and 10.6 years for controls; 53 of 89 patients had clubfoot. All foot measurements and scores on the OxAFQ significantly differed (p < 0.001) between patients and controls. Patients and their parents significantly differed on the physical (p = 0.03) and emotional (p = 0.02) domains of the OxAFQ, with parents' ratings being lower than their children. Moderate correlations (r = 0.54 to 0.059; p < 0.001) were found between physical domain (reported by parents on the OxAFQ) and dorsiflexion-knee flexed, and foot- arc-of-movement. Moderate correlations were found between physical domain (reported by children on OxAFQ) and foot-arc-of-movement (r = 0.56; p < 0.001). Patients in the surgical group showed moderate correlations (r = 0.57;, p < 0.001) between physical domain (reported by children on OxAFQ) and plantar flexion, and foot arc-of-movement. The control group and the patients in non-surgical subgroup showed no significant correlations.

CONCLUSION

Plantar flexion, arc of ankle ROM and hindfoot alignment impact foot function in children with foot deformities. Parents report significantly lower scores on the OxAFQ when judging foot functioning.

LEVEL OF EVIDENCE

Level II. Prognostic Studies.

Effect of Custom-Molded Foot Orthoses on Foot Pain and Balance in Children With Symptomatic Flexible Flat Feet

Objective

To evaluate the effect of custom-molded foot orthoses on foot pain and balance in children with symptomatic flexible flat foot 1 month and 3 months after fitting foot orthosis.

Method

A total of 24 children over 6 years old with flexible flat feet and foot pain for at least 6 months were recruited for this study. Their resting calcaneal stance position and calcaneal pitch angle were measured. Individual custom-molded rigid foot orthoses were prescribed using inverted orthotic technique to control foot overpronation. Pain questionnaire was used to obtain pain sites, degree, and frequency. Balancing ability was determined using computerized posturography. These evaluations were performed prior to custom-molded foot orthoses, 1 month, and 3 months after fitting foot orthoses.

Result

Of 24 children with symptomatic flexible flat feet recruited for this study, 20 completed the study. Significant (p<0.001) improvements in pain degree and frequency were noted after 1 and 3 months of custom-molded foot orthoses. In addition, significant (p<0.05) improvement in balancing ability was found after 3 months of custom-molded foot orthoses.

Conclusion

Short-term use of custom-molded foot orthoses significantly improved foot pain and balancing ability in children with symptomatic flexible flat foot.

The child with joint pain in primary care

Joint pains are a common reason for children to present to primary care. The differential diagnosis is large including some diseases that do not primarily affect the musculoskeletal system. Although the cause for many patients will be benign and self-resolving, in rare cases the diagnosis is associated with long-term morbidity and mortality if not detected early and appropriately treated. These include primary and secondary malignancies, septic arthritis, osteomyelitis, inflammatory arthritis, slipped upper femoral epiphysis (SUFE) and non-accidental injury. We highlight the importance of a thorough history and directed yet comprehensive examination. A diagnostic algorithm is provided to direct primary care physicians' clinical assessment and investigation with the evidence base where available. In many cases, tests are not required, but if there is suspicion of malignancy, infection or inflammatory conditions, laboratory tests including full blood count, blood film, erythrocyte sedimentation rate, C-reactive protein and lactate dehydrogenase help to support or exclude the diagnosis. Autoimmune tests, such as antinuclear antibodies and rheumatoid factor, have no diagnostic role in juvenile idiopathic arthritis; therefore, we advise against any form of 'rheumatological/autoimmune disease screen' in primary care. Imaging does have a place in the diagnosis of joint pains in children, with plain radiographs being most appropriate for suspected fractures and SUFE, whilst ultrasound is better for the detection of inflammatory or infective effusions. The appropriate referral of children to paediatric rheumatologists, oncologists, orthopaedic surgeons and the emergency department are discussed.

Short-term effects of backpack carriage on plantar pressure and gait in schoolchildren

PURPOSE

To assess the effects of backpack carriage on plantar pressure distributions and spatio-temporal gait parameters among children.

PARTICIPANTS

Two hundred-eighteen schoolchildren, aged 6-13, and attending primary and secondary schools in the city of Cagliari (Italy).

METHODS

Participants were tested at school, during regular days. A pressure plate and wearable inertial sensors were used to measure plantar pressures and spatio-temporal parameters of gait. Measures were obtained during both quiet standing and walking, and both with and without a backpack. The latter contained those items a child had on the testing day.

RESULTS

Participants carried a mean mass in their backpacks of 5.2 kg, and more than half had a backpack/body mass ratio higher than 15%. While spatio-temporal gait parameters were not affected by backpack carriage, significant increases (up to 25%) in plantar pressures were found during both static standing and walking, especially in the forefoot.

CONCLUSION

Under realistic conditions, the impact of backpack carriage was more evident on foot-ground interaction than on gait features. However, long-term consequences of altered plantar pressure need to be assessed in future work, considering the actual durations typically spent carrying school items.

Foot pain in the child and adolescent

There are multiple causes of pediatric foot and ankle pain. Although conservative measures are appropriate for initial management, patients with refractory pain should be given consideration for further intervention. This review highlights some of the most common causes of foot and ankle pain in the child, with specific attention to demographics, etiologies, diagnostic workup, and treatment options.

Current perspectives on ophthalmic manifestations of childhood rheumatic diseases

Inflammatory eye diseases are an important manifestation of many pediatric rheumatologic conditions. Early screening and diagnosis are imperative as these illnesses can not only result in significant visual morbidity but are also an indicator of systemic inflammation. Time to presentation of ocular inflammation varies significantly and can range from many years prior to the onset of systemic symptoms to well after the diagnosis of the rheumatologic disorder. Due to this variability in presentation, careful monitoring by an ophthalmologist is vital to preventing ocular complications and preserving vision. Both local and systemic immunosuppressive medications have been effective in the management of ocular disease. In this review, we will focus on the known ophthalmologic manifestations of common pediatric rheumatologic diseases and discuss recent advances in therapeutic considerations for these conditions.

Pediatric flexible flatfoot; clinical aspects and algorithmic approach

Flatfoot constitutes the major cause of clinic visits for pediatric foot problems. The reported prevalence of flatfoot varies widely due to numerous factors. It can be divided into flexible and rigid flatfoot. Diagnosis and management of pediatric flatfoot has long been the matter of controversy. Common assessment tools include visual inspection, anthropometric values, footprint parameters and radiographic evaluation. Most flexible flatfeet are physiologic, asymptomatic, and require no treatment. Otherwise, the physician should treat symptomatic flexible flatfeet. Initial treatment options include activity modification, proper shoe and orthoses, exercises and medication. Furthermore, comorbidities such as obesity and ligamenous laxity should be identified and managed, if applicable. When all nonsurgical treatment options faile, surgery can be considered. Our purpose in this article is to present a clinical algorithmic approach to pediatric flatfoot.

The puzzling clinical spectrum and course of juvenile sarcoidosis

BACKGROUND

Juvenile sarcoidosis is a rare, chronic, multisystem, granulomatous disease of obscure etiology which is seen in childhood and adulthood. The disease in childhood has a course different from that in adulthood.

DATA SOURCES

PubMed database was searched using terms sarcoidosis, children or childhood sarcoidosis or juvenile sarcoidosis in combination with one of the following terms: epidemiology, clinical manifestations, genetics, diagnosis, treatment, and prognosis. We also retrieved the terms such as early onset sarcoidosis and Blau syndrome. Furthermore, e-medicine and European Respiratory Society monographs for sarcoidosis were reviewed.

RESULTS

Sarcoidosis in childhood presents with two age dependent, distinct forms. In younger children it is clinically evident before the age of four years and characterized by the triad of rash, arthritis and uveitis. In their older counterparts, the juvenile late onset sarcoidosis involves several organs and its clinical appearance resembles the adult type of the disease, with the respiratory system being most frequently affected (hilar lymphadenopathy, pulmonary infiltrations). Steroid is the main agent of treatment whereas methotrexate is also used for beneficial steroid sparing effects. New, novel therapies may change the outcome of the disease especially in difficult morbid cases.

CONCLUSIONS

Sarcoidosis in childhood is recognized as a systemic disease affecting various organs and having diverse clinical course depending on the age of onset.