1. Overview of the Pediatric Foot Dr. Kristina L. Petrocco-Napuli 1

2. Objectives -Discussion of the anatomical development of the pediatric foot and how this impacts gait. -Identify commonly seen conditions of the pediatric foot and how to identify abnormality. -Discussion and identification of treatment options associated with the pediatric foot. 2

3. Lower Limb Development and Anatomical Structures 3 http://www.travelingsloan.com/2014/05/24/welcome-to-the-world-little-one/

4. Embryology and Lower Limb Development First hint of the lower limb can be seen in week 3 embryo Week 4: the limb buds form End of week 4: 3 regions have developed (thigh, leg and foot) 4-8 Weeks for Lower Extremity Development Approx 33-54 days 4

5. Anatomy of the Pediatric Foot 5 http://www.eorthopod.com/flat-feet/topic/232 www.pedrad.org

6. Anatomy of the Pediatric Foot 6 http://www.slideshare.net/AkramJaffar/anatomy-of-the-ankle-and-joints-of-foot

7. The Pediatric Lower Limb 7 http://pediatriccare.solutions.aap.org/chapter.aspx?sectionid=108724192&bookid=1626

8. Motor Development in Children Begin sitting around 6 months Crawling 9 months Walking 10-16 months of age 8 http://www.dailyfinance.com/2014/08/28/dividend-stock-picks/

9. Growth of the Pediatric Foot Walking by the age of 1 Feet grow in spurts New shoes every 3-4 months depending on age 9

10. 10 Rate of Pediatric Foot Growth Age Early Toddlers (Under 16 months) Toddlers age 16-24 months Young Child 24-36 months Children over 3 years old Foot Growth More than 1.5 of Size Approx. 1.5 foot growth size 1.5 foot growth size Months 2 monthsEvery 3 months Every 4 months Every 4-6 months Foot growth is parallel in boys and girls Boys tend to have on average one size longer and wider Foot Ankle. 1990 Feb;10 (4): 211-3. Foot Growth In Children Age One to Five Years Gould, N. Moreland M, Trevino S, Alvarez R, Fenwick J, Bach N

11. Assessment and Conditions of the Pediatric Foot 11 https://www.pinterest.com/source/waterloo.k12.ia.us

12. Pediatric Gait http://www.whattoexpect.com/first-year/week-52/happy-birthday.aspx Age 3:display a clear adult gait pattern 12

13. Arches Develop around the age of 5 Cause for concern of parents Pes planus is hereditary and more common in children that wore shoes when young – Closed toe shoes inhibited the development of arch formation – Flexible painless flat foot is the largest population; approx 45% of preschool population 13

14. Assessment: Arches Observe general limb alignment Varus/Valgus Subtalar joint Heel cord tightness Weight bearing: foot appears flat and heel may exhibit mild valgus Tip toes: arch reconstructs Severe flexible flat foot: medial sole wear (1-2 weeks of abnormal wear in a new shoe) 14

15. Flexible Pes Planus Flexible flat foot is pathological when pain is present in the arch May have callouses and abnormal shoe wear Treatment 15 https://en.wikipedia.org/wiki/Children%27s_feet

16. Pes Cavus High arches Not common If present: inherited or indicative of genetic neurological condition Ankles sprains are more likely with this foot posture 16 http://www.seattlechildrens.org/medical-conditions/ bone-joint-muscle-conditions/feet-leg-malformations/cavus- foot/

17. Calcaneovalgus Deformity Congenital Due to intrauterine deformity 30-50% of infants have this bilaterally There is no abnormality of the bones or joints 17 http://www.zadeh.co.uk/paediatricorthopaedics/paediatricorthopaedics.htm

18. Calcaneovalgus Deformity Assessment: 4-5 days after birth – Acute dorsiflexed position – Superior portion of the foot in contact with the anterolateral surface of the leg – Heel is in dorsiflexion and forefoot is abducted Treatment: -Resolution over time 18

19. Congenital Vertical Talus Most serious pathological flat foot dx Correlated with other congenital anomalies – Developmental dysplasia of the hip – Myelomeningocele http://orthoinfo.aaos.org/topic.cfm?topic=A00612 Signs and Symptoms: Rigid flat foot, valgus position of heel, contracture of triceps surae, * convex arch 19

20. Calcaneal Apophysitis aka Sever’s Disease Painful inflammation of the epiphyseal plate of the calcaneus Common cause of pain in growing children more so in those that are physically active Most common during adolescence, approx the 2 year period in early puberty where growth occurs most rapidly Calcaneus fuses by age 15 20

21. Juvenile Bunion Occurs in children that are ligamentous lax Surgical correction is restricted until the end of growth 21 http://yourchildsfoot.blogspot.com/2012/02/does-my-child-need-bunion-surgery.html

22. Educating Parents About Footwear 22 http://lgmontessori.com/links-to-parents/

23. Educating Parents: Choosing the Right Footwear Pre-walkers: -No shoes are best; use booties/socks instead -Flexible Shoe and wide Toddlers: -Avoid synthetic materials -Sole of shoe should be smooth -Lightweight -Wide toe box -Barefoot is best! 23

24. Educating Parents: Choosing the Right Footwear School Aged Children – Flexible – Well ventilated shoe Teens/Sports – Get fitted at a sports store for athletic wear – Shoes should be flexible at the toe and heel – Socks need to worn – Watch for signs of wear – Flip Flops/ Heels/Slip On Shoes 24

25. Educating Parents: Choosing the Right Footwear Look for a stiff heel Toe flexibility Rigid Middle 25 http://www.painfreefeet.ca/index.cfm?id=24699

26. Educating Parents: Choosing the Right Footwear Make sure to measure each time you shop Shop late in the afternoon as feet tend to swell Never hand down shoes Always buy for the larger foot Shoes should be comfortable right away, there should not be a “break-in” period 26

27. Case Study: 8 year old Female Gymnast 27

28. Orthotics 28

29. Questions? 29

30. Contact Information Dr. Kristina Petrocco-Napuli drkrispn@icloud.com On Twitter @drkrispn 30

31. References American Podiatric Medical Association http://www.apma.org/index.cfm American Academy of Pediatrics https://www.aap.org/en-us/Pages/Default.aspx Chard A, Greene A, hunt A, Vanwanseele B, Smith R. Effect of Thong Style Flip-Flops on Children’s Barefoot Walking and Jogging Kinematics. J Foot and Ankle Res. 5;6(1):8 (2013) Gould N,Moreland M, Trevino S, Alvarez R, Fenwick J, Bach N. Foot Growth in Children Age One to Five Years. Foot Ankle. 10 (4):211-3. (1990) Gould N, Moreland M, Alvarez R, Trevino S, Fenwick J. Development of the Child’s Arch. Foot Ankle. (5):241-5 (1989) Price C, Andrejevas V, findlow AH, Graham-Smith P, Jones R. Does Flip Flop Style Footwear Modify Ankle Biomechanics and Foot Loading Patterns? J Foot and Ankle Res. 26;7(1) (2014) Rose R. Flat Feet in Children: When Should They be Treated? The Internet Journal of Orthopedic Surgery. Vol 6, No1. (2006) 31