Pediatrics

The information below addresses many of the more common issues relating to issues that children may have with their feet, toes, toenails, and development.  We commonly see children in our clinic for the majority of the listed reasons in this page, including: Ingrown Toenails; Flat Feet; Sever’s Disease; Hyperhydrosis; Plantar Warts; Molluscum Contagiosum; Juvenile Bunion; Curved Toes; and Toe Walking.

There are numerous methods to treat these issues, which we go into detail below about some of the more common methods, including home remedies and tips and tricks to try to address the issue and avoid a visit to the doctor.  Our Conditions page also addresses several of these issues individually and how these issues may be treated for adults.

Ingrown Toenails

An ingrown toenail is a condition where the border, or side of the nail, digs into the flesh of the toe causing pain, redness, swelling, and warmth to the toe.  If the offending nail border is not removed it will continue to grow into the tissues and may become infected.  Patients often complain that the toe is so painful that ever having the bed sheets rest on the toe are painful.  Ingrown toenails most commonly occur on the big toe but can occur at the border of any toenail. 

Children often present with severely ingrown toenails.  Children are reluctant to let their parents know they have an ingrown toenail because they are afraid of having to go to the doctor and getting a shot.  As a result, ingrown toenails often present much worse in children than in an adult. 

Ingrown toenails are one of the most common conditions seen in podiatrist’s office and they are especially common in children.  The reason for this is because the number one cause of ingrown toenails is not cutting them properly.  Picking and biting your toenails counts as not cutting them properly.  Kids tend to have these bad habits. 

CAUSES OF INGROWN TOENAIL

Improperly cutting, biting, or picking of toenails: This is the number one cause of ingrown toenails.

Trauma: stubbing your toe or dropping something on your foot can cause an ingrown toenail.

Ill-fitting shoes: Shoes should be sized appropriately.  Children can grow out of their shoes within weeks during a growth spirt.  Tight shoes are a big reason that children develop ingrown toenails.

Sweaty feet: It is not uncommon for kids to develop very sweaty feet in their teens when they hit puberty.  This is a condition called hyperhidrosis (hyperlink).  Patients with hyperhidrosis are more likely to develop an ingrown toenail.

Nail fungus: Toenail fungus (onychomycosis) causes an increased incident of ingrown toenails.  Fungal toenails tend to become very thick.  This thickening of the nail increases the likelihood of developing an ingrown toenail. 

Genetic factors: some people are just doomed to develop ingrown toenails.  Factors such as a pincer toenail (hyperlink to Pincer toenail-KD device) greatly increase the chances of developing an ingrown toenail.  A bulbus or fat toe will also increase your risk.  The flesh of the toe will envelop the side of the toenail resulting in an ingrown toenail. 

Home remedies for ingrown toenails

Soaking the foot in warm water and Epsom Salt may decrease inflammation at the side of the toe allowing the nail to grow out.  Epsom Salt is a drying agent that helps sooth the inflamed tissues around the ingrown nail border.  Soaking instructions are; one heaping table spoon of Epsom Salt per gallon of warm water.  Soak the foot for 15 to 20 minutes twice a day. 

Another home remedy is to stuff a very small wisp of cotton under the nail border.  This will lift the nail off the tissues and train the nail to grow straight.  The cotton should be replaced daily. 

Home remedies are generally not recommended for people with other medical conditions such as diabetes, poor circulation, or nerve problems. 

How serious are ingrown toenails?

Ingrown toenails can be dangerous because if they become infected, the infection can spread to the bone.  If the bone becomes infected, it is called osteomyelitis.  Osteomyelitis is much more serious and may require IV antibiotics.  In severe cases osteomyelitis may result in amputation of the toe. 

Unfortunately, osteomyelitis from an ingrown toenail is more common than most people think.  This is because there is very little soft tissue in the toes.  An infected toenail does not have to spread very far to reach bone.  Patients with other medical factors such as diabetes, poor circulation, and nerve damage are at much higher risk of bone infection. 

How should I cut my toenails?

The best way to prevent ingrown toenails is to make sure they are cut properly.  Toenails should be cut straight across.  They can be curved somewhat to follow the contour of the toe but avoid cutting them down in the corners. 

Other Tips:

Don’t cut nails too short

Don’t pick or bite your nails

Wear shoes that fit correctly

Avoid wearing tight socks or stockings

What can I expect when I come to the podiatrist with an ingrown toenail?

Your doctor will first take a full history to see if you have other risk factors such as diabetes, poor blood flow, etc.  If the ingrown is imbedded deep into the tissues your podiatrist will likely give you a small injection to numb the area.  This shot is further back on the toe and not directly into the painful ingrown toenail site.  Cold spray is sprayed at the site prior to the injection which decreases the sensation of the injection.  Once the area is numb a small blade is used to cut a few millimeters of nail away from the side of the toe.  This portion of the ingrown toenail is then removed.  Once the offending nail has been removed your doctor will clean out the nail border with an instrument called a curette and inspect the site for signs of infection.  For chronic ingrown toenails the site is then treated with a chemical called Phenol.  This chemical destroys the root of the nail in the corner to prevent the ingrown from reoccurring.  Antibiotic ointment and a bandage are then applied. 

The entire procedure takes about 10 minutes.  Post-operative instructions are as followed:

Soak the foot is warm water and Epsom Salt for 15 minutes twice a day.

Apply antibiotic ointment to the site and cover with a bandage.

Moderate drainage is normal and nothing to be alarmed about.  If a permanent procedure is performed with the chemical Phenol there is more drainage.  The drainage is the bodies reaction to the Phenol and nothing to be alarmed about.  There is mild to moderate pain for a day or two after the procedure, but most kids can go back to school the next day in their regular shoes and resume sports in 3-4 days. 

ONE WEEK LATER

This is the same patient as above just 1 week after the procedure.  The side of the toe is almost completely healed.

What if my child will not sit still for the injection or the procedure?

For very young children or kids that are petrified of needles the procedure can be performed under sedation.  This decision will be up to the parents and physician. 

 

 

 

Flat Feet

Flat feet are one of the most common reasons parents bring their children to see a podiatrist.  Adults with flat feet are often afraid that their child might inherit their foot type.  In adults, flat feet are linked to a laundry list of ailments such as arthritis, stiffness, tendinitis, bunions, hammertoes and much more.

In children, flat feet can be part of normal development and no cause for alarm.  It is normal for a child’s foot to appear flat up to about the age of 2, due to a thick layer of baby fat that fills the arch area.

As children continues to grow, their legs go through normal stages of development where by the knee moves inwards and outwards in relation to the long axis of the leg.  During these stages the foot and ankle struggle to keep the foot flat on the ground and at times may appear flat.   Gait may also appear awkward during these phases.

From birth to 18 months an infant’s knees begin to move outward to the sides in relation to the legs and the legs become bowed.  The medical term for bow legged is genu varum.  At 18 months the legs begin to straighten out and are straight by age 2 years.  After age 2 the legs begin to move in the other direction and the knees become knocked.  The knock knees are at their most extreme around age 3 or 4 years.  The medical term for knock knees is genu valgus.  By 7 years of age the legs straighten out and remain straight.

 

 

 

 

10 month old with normal developmental bow legs (Genu Varum)

By 2 years legs straighten

Normal knock knees (Genu Valgum) in a 5 year old child.

By 8 years legs straight and remain straight

There are parameters of normal for these various stages and your physician can examine your child’s feet to determine if they are within normal limits.

Painful feet in children is never normal and depending your child’s age, they may not know how to interpret or express pain.

CHILDREN OFTEN EXPRESS THEIR SYMPTOMS WITHOUT REPORTING ANY PAIN.  LOOK FOR THESE SIGNS INSTEAD……

Frequently ask to be carried.

They may seem lazy.

Prefer sedentary activities.

Have trouble keeping up with their peers.

When a child has a severe flat foot, they will not only have a low arch but an inward bowing of the inside of their ankle.  They may look like they have a nice arch when non-weight bearing but it completely flattens out when standing.  This is usually a flexible developmental flat foot and can lead to postural complaints and poor muscle development.  Treatment options become more limited the older the child becomes.

Often simple changes in shoe gear and custom inserts can help your child run, jump, and play with their friends without pain.

Calcaneal Apophysitis (Sever’s Disease)

Calcaneal apophysitis is a painful inflammatory condition of the growth plate found at the back of the heel.  The condition is also called Sever’s disease, although technically it is not a disease.  Pain is usually located where the back of the heel meets the bottom of the heel.  Pain will increase during activity and is more common in boys because boys tend to be more physically active than girls.

Symptoms of calcaneal apophysitis are very similar to the symptoms of plantar fasciitis (hyperlink to plantar fasciitis page).  The distinction is made mostly by age, it is almost unheard of for kids to develop plantar fasciitis.  Calcaneal apophysitis occurs in children between ages of 8 and 14 years. 

ANATOMY LESSON

An apophysis is a normal bony outgrowth that arises from a separate ossification center and eventually fuses with the bone at maturity.  The actual growth plate is called the physis. 

The heel bone (calcaneus) is formed from two different growth centers.  Once the heel bone has finished growing the two bones fuse together to form one adult heel bone.  Calcaneal apophysitis occurs as these two bones are in the process of fusing, they begin to rub on one another, resulting essentially in an arthritic type of pain.  The condition is more common in active children, especially boys that play a lot of sports.  During running and jumping the Achilles tendon pulls up on the apophysis and grinds against the main body of the heel bone. 

Your podiatrist will diagnose the condition clinically and with x-rays.  Calcaneal apophysitis can begin as early as 7 or 8 years of age as the growth plate begins to fuse.  By age 14 or 15 years old the growth plate will fuse, motion will stop, and pain will go away.

X-rays

X-rays are helpful for making the diagnosis of calcaneal apophysitis.  X-rays are also important to rule out other potential causes of pain such as infection, stress fracture, or tumors.  Radiographic signs of calcaneal apophysitis include sclerosing or thickening of the apophysis.  Sclerotic or thick bone will appear more “white” on x-ray as compared to surrounding bone.  In addition, the apophysis may be fragmented or fractured with calcaneal apophysitis. 

Treatment

Treatment for calcaneal apophysitis is aimed at decreasing movement at the site of the growth plate.  This requires a decrease in activity, which can be a tall order for young active kids who want to play sports. 

TREATMENT FOR CALCANEAL APOPHYSITIS (SEVER’S DISEASE)

Activity modifications

Anti-inflammatories

Achilles stretching exercises

Heel lift in shoes

Short leg walking cast – for severe cases

The good news is that the calcaneal apophysitis is self-limiting and almost always goes away eventually. 

Once the growth plate finally fuse together motion at the site stops and pain stops.  The pain can linger, however, for up to 18 months while the growth plate fuses.

 

Hyperhydrosis

Hyperhydrosis is the medical term for excessive sweating.  While it is not a pediatric condition per se, it tends to begin in adolescence when kids enter puberty.  The condition occurs for no apparent reason and is termed primary hyperhidrosis.  It usually affects only certain areas so is termed primary focal hyperhidrosis.  Besides the feet, the other common areas affected are the hands and the armpits.  If excessive sweating occurs due to another condition such as high blood pressure or hyperthyroidism it is termed secondary hyperhidrosis. 

The biggest complaint with primary focal hyperhidrosis of the feet is smell.  People with sweaty feet have stinky feet.  Sweat has very little odor but the moisture from excessive perspiration creates the perfect environment for bacteria to grow.  It is the bacteria that smell bad. 

Treatments for sweaty feet are aimed at keeping the feet dry.  Some of these things can be done at home and possibly save a trip to the doctor’s office.  Soaking the feet in warm water and Epsom Salt for 15-20 minutes a day is helpful.  Epsom Salt is an astringent which means it tends to dry the feet out.  Regular table salt will also work.  Wear breathable shoes to allow air exchange which will assist with evaporation of sweat.  Changing your socks twice a day is also beneficial.  Putting on a fresh dry pair of socks half way through the day will help keep the bacteria at bay.  Speaking of socks, stay away from cotton.  Cotton socks are highly absorbent and hold the moisture against the skin creating an ideal environment for bacterial growth. Socks (hyperlink to sock section) made of synthetic material are recommended.  Synthetic socks wick moisture away from the skin keeping the feet dry. 

If these home treatments fail your podiatrist can prescribe an antiperspirant specially made for the feet.  Antiperspirant for the feet has the consistency of water, it is not goopy like underarm deodorant.  Some podiatrist recommend applying the antiperspirant at bedtime and wrapping the foot in Saran wrap and then putting socks on.  In the morning removed the Saran wrap.  This holds the antiperspirant against the skin without rubbing off during the night.  This only needs to be done for about a week, after that just a daily application will suffice.

There is also a machine called an Iontophoresis machine that consists of 2 containers of water a unit that puts a small electrical current through the water and decreases sweating.  This unit is prescription only and sometimes covered by insurance.  There are several companies that manufacture this product Hidrex, Idromed, and R.A. Fischer. 

Lastly, Botox injections work well for excessive sweating.  Botox paralyses the sweat glands preventing them from excreting sweat.  The downside of Botox is that it requires quite a few shots in the feet and only last for about 3 to 4 months. 

 

Plantar Warts

Plantar warts (verruca plantaris) are benign flesh colored skin growths caused by a viral infection.  Most come from the human papillomavirus (HPV).  They are contagious and common in children.  Most adults have been exposed to the viral strains and developed immunity.

Plantar warts differ from all other warts in that they can cause pain.  The pain comes from weight bearing on the lesions.  A callus commonly develops over the top of plantar warts from walking on them.  As a result, plantar warts are often misdiagnosed as a simple callus but an experienced podiatrist can distinguish the difference.   Warts can spread if left untreated.  Multiple warts can coalesce and form mosaic warts.  Picking, scratching, or biting, warts can lead to autoinoculation.  Autoinoculation is where you transfer the wart from one area of the body to another. 

Plantar warts come in all shapes and sizes.  They often have a rough surface with tiny black dots in them.  The black dots are small capillaries that have been drawn up from deeper in the skin to feed the wart.    When left untreated they can grow into large horn like projections. 

  

  

How did I become infected with a wart?     


You cannot catch a wart from touching a frog or toad.  You catch a wart from having a break in the skin and a viral particle entering your body.  The virus that causes warts is ubiquitous.  They are everywhere, in our shoes, on our hands, on door knobs, in the pool.  The best defense against becoming infected with a wart is intact skin.  To become infected there has to be a break in the skin.  We all have microabrations in our skin and this is all the opportunity the virus needs to invade the skin.  Warts also find it easier to invade the skin if the skin is wet, thus public pools, showers, locker rooms are common sites of infection.  It can be difficult to determine exactly when you became infected with a wart because the incubation period is from 1-8 months.

Treatment for warts

Treatment of warts is a very broad topic.  They can be burned off, frozen off, or cut out.  Having said that some studies show that, on average, half of all warts resolve spontaneously within 18 months without any treatment.

Over the counter wart treatments

There are many over the counter medications to treat warts but they are not very effective and if used improperly they can actually spread the wart.  If the medications are come in contact with the skin surrounding the wart, they can damage this intact skin and create an avenue for the wart to spread.  Diabetics, immunocompromised individuals, and people with circulation problems should not self-treat their warts.  Over the counter wart treatments come in two forms; those containing salicylic acid and cryotherapy treatments.    

Salicylic Acid

Over the counter topical liquids, gels, pads, plasters, and ointments all contain Salicylic acid as their active ingredient.  Salicylic acid is an acid that dissolves away the skin cells containing the wart particles.  Compound W and DuoFilm are two of the more commonly recognized products.   

Cryotherapy

Cryotherayp freezes the top layer of skin, killing the wart in the process.  Over the counter aerosol wart treatments use sprays at a temperature of -90 degrees Fahrenheit (-57 degrees Celcius).  This temperature is usually not cold enough to kill the wart.  The liquid nitrogen spray the doctor uses is -320 degrees F (-196 degrees C).

 

 

What will the doctor do for my wart?

If your child’s warts are not going away, or if they are getting bigger, it’s time to see a podiatrist.  There are many treatments physicians have for eliminating warts that are not available over the counter. 

Liquid Nitrogen

Spraying the wart with liquid nitrogen is a common ‘go to’ treatment.  This therapy can be painful, as the freeze spray is very cold. 

High strength salicylic acid

There are multiple topical treatments available at the physician’s office not available over the counter.

Bleomycin

Intra-lesional injections of Bleomycin is very effective.  Bleomycin is an anti-cancer drug that inhibits DNA synthesis in cells and viruses.  The area is first numbed with local anesthetic and the warts are directly injected with the Bleomycin.  A blood blister soon forms with the wart in the roof of the blister.  The wart turns black and after a few weeks falls off or is removed by your doctor. 

Surgery

If all else fails, the wart can be surgically removed.  This treatment tends to be offered when other wart treatments have failed or if the wart is of a certain size.  There are two types of surgical removal.  The preferred method is curettage.  With curettage the wart is essentially scrapped off the basal membrane of the skin.  This technique debulks the wart, it does not necessarily remove all viral particles.  The immune system will do that during healing.  If performed correctly, there is minimal scarring and very effective in eliminating warts. 

The second surgical technique is a full thickness excision of the skin containing the wart.  This technique required stitches and will leave a scar.    

Can DUCT TAPE cure a wart?

Duct tape has received a lot of press as a cure for plantar warts and there has been several scientific studies showing that indeed it does work.  Most notably a 2002 study were 61 children enrolled.  Half were treated with liquid nitrogen and the other half with duct tape.  After 2 months 60% of the children treated with liquid nitrogen had resolved and 85% of the children treated with duct tape had resolved.  Many doctors, however, insist it’s no better than a placebo.  Still, as a home remedy it may be worth a try. 

THE DUCT TAPE TREATMENT IS AS FOLLOWED:

-Apply duct tape to wart and leave it on for 6 days, replace with new duct tape if it falls off. 

-After 6 days, remove the duct tape and soak the foot for about 5 minutes.

-Debride (sand down) the wart with a pumice stone or emery board and leave the tape off on the 7th day.

-The next day repeat the process, continue until wart resolves.   

How does duct tape work to kill a wart?

No one really knows.  There are two theories.  Some researchers say duct tape works by stimulating the patient’s immune system.  This results in what is called the “Innocent bystander” treatment.  By alerting your body’s immune response to an area of the skin with the duct tape, you are helping your body’s own immunity to recognize the virus (wart).  Others say that duct tape works by “suffocating” the wart.  With the wart being completely covered, it is cut off from getting oxygen.  This eventually suffocates the wart and it will die.  Nail polish has also been described to be effective is suffocating the wart. 

What can I do to avoid getting a wart?

Avoid contact with anyone who has one.  Keep your feet covered in public places.  Keep in mind that the virus can live on towels, doorknobs, light switches for months and still be infectious. 

 

Molluscum Contagiosum

Molluscum Contagiosum is a viral infection in the skin similar to a wart.  They start out quite unassuming but can spread quite rapidly.  They present as a small pink or flesh colored lesion with a dimple in the center.  They appear similar to a pimple or ant bite but linger for weeks or months.  As the name implies, Molluscum Contagiosum is quite contagious and can easily spread from person to person.  Children pick up molluscum by direct contact through playing and wrestling.   Sharing cloths or towels is another common way the virus is spread. 

Molluscum is especially prevalent in the south because the virus thrives in a warm humid environment.  Molluscum contagiosum is diagnosed clinically.  The lesions are quite distinct but can sometimes be confused with warts or chickenpox.

TREATMENT FOR MOLLUSCUM CONTAGIOSUM

Molluscum Contagiosum is self-limiting and usually resolves in about a year.  While treatment is not required, it can be beneficial.  Treatment can prevent spreading the condition to other parts of the body or to other children.  Treatment can also prevent the lesions from growing out of control on children who are immunocompromised. 

Treatment of Molluscum Contagiosum is very similar to treatment for warts and may include:

Cryosurgery-freeze the lesions with liquid nitrogen.

Laser-lesions are destroyed with thermal heat from a laser.

Curettage-lesions are picked open with a needle and the center of the lesion which contains infectious Handeson Petterson bodies (HP bodies) are scraped off. 

Topicals-there are many topical agents that can be applied to destroy the lesions.

 

Juvenile Bunion

While bunions are not terribly common in children, it is beneficial to diagnose and treat them as early as possible.  A bunion deformity is a condition where the bone attached to the big toe (1st metatarsal) becomes hypermobile and begins to veer out towards the other foot.  Due to the way the tendons function in the big toe, this metatarsal movement causes the big toe to lean in the opposite direction and crowd the other toes.   Bunions result in joints being out of alignment which can lead to arthritis if left untreated.  The treatment goal is to prevent the bunion from getting larger and relieve pain. 

Bunions are hereditary and examining the parents or grandparents feet can be beneficial in determining how the childs feet will end up.  Bunions develop from an abnormal foot type, the abnormal foot type can often be easily addressed with custom molded orthotics. (hyperlink to orthotic section) By realigning the foot the abnormal forces that lead to a bunion development can be eliminated. 

Most surgery on the foot is safer once the child has stopped growing.  Surgery can damage growth plates which affect the growth of the bones in the foot.  Having said that, there is a minimally invasive surgery recommended for juvenile bunions if they are severe.  This surgery actually redirects the growth plate, so the bunion corrects itself.  The procedure is called a Lateral Hemiepiphysiodesis.  As the 1st ray is actively growing a surgical staple is placed on one side of the growth plate.  This causes asymmetrical growth of the bone and forces the bone to grow inward.  This inward growth realigns the 1st ray and, over time, corrects the bunion.  The procedure is much less invasive than performing a true “bunionectomy”. (hyperlink to bunions).

If surgical timing is right, the staple can be left in permanently.  However, if the bunion straightens out and the bones are not finished growing, the staple will have to be removed to prevent over correction.

Curled Toes

Curled toes are common in children.  Curled toes are medically referred to as hammertoes.  They are often a concern for the parents, however, they rarely develop into any major issues.  They are usually asymptomatic and pose no medical problems.  Normal embryotic development predisposes the 3rd, 4th, and 5th toes to be slightly flexed and curled inward.  This curvature to the toes may or may not straighten out as the child grows.  If the toes are excessively curled they may cause pain or callus to develop from the ground or neighboring toes.  In these incidences treatment is warranted.

Treatment usually begins with stretching and taping techniques in an effort to realign and straighten the toe.  Surgical correction is always an option but usually not recommended until the child has finished growing.  Believe it or not all the toes in the foot except the big toe have three bones in them, even the pinky!

Each of these three bones has a separate and distinct growth plate.  Surgery performed on children’s toes run the risk of damage to these growth plates.  This may cause the toes to curl even more or stunt the growth of the toe.    

Toe Walking

When children first begin to walk they often walk on their toes.  This is because the Achilles tendon needs some time to stretch out and allow the foot to sit flat on the floor.  Toe walking should decrease as the child progresses and should not be present past age 3 years.  Some children continue to toe walk out of habit. 

Treatment for toe walkers may include

Physical Therapy-The goal of PT is to stretch out the calf muscles.

Leg braces or splints-There are many types of braces and special splints for toe walking.

Serial casting

Botox injections-Botox paralyses muscle.  It has shown to be successful by injecting into the calf muscles.

Surgery-In severe cases the Achilles tendon is lengthened.

There are some pathological reasons for toe walking, most notably cerebral palsy.  Toe walking has also been reported as an early sign of autism.  For these reasons, children who toe walk should be brought in to the podiatrist for an evaluation.

Questions?

Contact our clinic today.

 

At Gulf South Foot & Ankle we are dedicated to helping you with all your foot and ankle problems. Contact our office by filling out the following form or calling us at (504) 454-3004 and we will be happy to answer your questions.

 

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