Flexible Flatfoot in Children

by Christi Abeln, MS, APRN, BC

Pediatric Orthopedics
 

Flexible flatfoot is a condition in which the arch of the foot shrinks or disappears upon standing. Upon sitting or when the child is on tiptoes, the arch reappears. Parents and other family members often worry needlessly that an abnormally low or absent arch is a child's foot will lead to permanent deformities or disabilities. Most children eventually outgrow flexible flatfoot without any problems. The condition usually is painless and does not interfere with walking or sports participation.

 

Symptoms

A flexible flatfoot has normal muscle function and good joint mobility and is considered to be a variation of normal. As the child grows and walks on it, the foot's soft tissues tighten, shaping its arch gradually. Flexible flatfoot often continues until the child is at least age 5 years or older. If flexible flatfoot continues into adolescence, the child may experience aching pain along the bottom of the foot. A doctor should be consulted if the child's flatfeet cause pain.

Diagnosis

To make the diagnosis, the doctor will examine the child to rule out other types of flatfeet that may require treatment. These include flexible flatfoot with tight heel cord, or rigid flatfoot, which is a more serious condition.

The doctor will look for patterns of wear on the child's everyday shoes. Tell the doctor if anyone else in the family is flatfooted, as this may be an inherited condition. It is important to know about any known neurological or muscular disease in the child.

The doctor may ask the child to sit, stand, raise the toes while standing, and stand on tiptoe. He or she will probably examine the child's heel cord (Achilles tendon) for tightness and may check the bottom of the foot for calluses.
 

Treatment
Nonsurgical treatment
Treatment for flexible flatfoot is required only if the child is experiencing symptoms of discomfort from the condition.

If the child has activity-related pain or tiredness in the foot/ankle or leg, the doctor may recommend stretching exercises for the heel cord.

If discomfort continues, the doctor may recommend shoe inserts. Soft-, firm-, and hard-molded arch supports may relieve the child's foot pain and fatigue in many cases. They can also extend the life of his or her shoes, which may otherwise wear unevenly. Sometimes a doctor may prescribe physical therapy or casting if your child has flexible flatfoot with tight heel cords.

Surgical treatment
Occasionally, surgical treatment will be necessary for an adolescent with persistent pain. A small number of flexible flatfeet become rigid instead of correcting with growth. These cases may need further medical evaluation.

What is the Young Athlete Center?

Clinicians from Washington University and St. Louis Children’s Hospital have teamed up to form the all new Young Athlete Center, a program designed to provide comprehensive care for pediatric and adolescent athletes of all abilities with sports-related injuries. The Young Athlete Center has a multidisciplinary treatment approach, working in collaboration with physicians and clinicians from a variety of specialties, including orthopedics, sports medicine, physical therapy, adolescent medicine, pain management, sports psychology, rheumatology, cardiology, nutrition and more. Together this multidisciplinary team provides care for any health issues a young athlete may encounter.

The Young Athlete Center offers:

• Same-day appointments
• Comprehensive evaluations by Washington University orthopedic and sports medicine physicians
• On-site radiology, imaging, casting and splinting services
• Nonsurgical management of sports-related injuries
• Minimally invasive, surgical treatment of sports-related injuries, with same-day discharge
• Pediatric specialty care of fractures
• Sports-related concussion assessments
• Orthopedics, sports medicine, physical therapy, pain management, sports psychology, adolescent medicine, nutrition, rheumatology, cardiology, and others

The Young Athlete Center is directed by Jeffrey Nepple, MD, a pediatric orthopedic and sports medicine physician, and Mark Halstead, MD, a non-surgical sports medicine physician, both physicians at Washington University Orthopedics. The Young Athlete Center is located at the all new St. Louis Children’s Specialty Care Center in West County, with additional services at St. Louis Children’s Hospital in the Central West End.

Injury Prevention Education
The Young Athlete Center is also committed to improving injury prevention in youth sports. Nearly 3.5 million injuries occur in youth sports each year, with up to half of these being overuse injuries that could be prevented. The Young Athlete Center provides education on sports injuries and injury prevention through many methods, including social media, blog posts and public events. The Young Athlete Center hosted its first event, PlayFit, Stay Fit! on August 8, from 9am-noon at the new St. Louis Children’s Specialty Care Center. This  free, open house event included lectures from Washington University clinicians on injury prevention, sports concussions, sports anxiety and more. Participants had a chance to meet Orlando Pace, former offensive tackle for the St. Louis Rams, the official mascots of the St. Louis Rams and Blues, enjoyed wholesome snacks and refreshments, took home great giveaways, played fun games and activities, and took a tour of the new St. Louis Children’s Specialty Care Center. The Young Athlete Center also plans to host a lecture series for parents and coaches on common sports topics in the coming months; additional information on this lecture series will be announced soon.  

More Information:

• Schedule an appointment with the Young Athlete Center: 314-514-3500 or request an appointment online
• Learn more about common conditions treated by the Young Athlete Center
• Register for the Play Fit, Stay Fit! event online or call 314.454.KIDS (5437)
• Follow the Young Athlete Center on Twitter (@stlyac)      

Lessons from The Sports Gene

I recently read the New York Times Bestseller, The Sports Gene, by David Epstein and wanted to share a few thoughts.

I thoroughly enjoyed the book and recommend it to anyone interested in high level sports performance.  The book is well written and filled with fascinating stories.  It delves into the medical side of genes (hence, the title) with a bit of science which may not be enjoyable for everyone.  Each of the 16 chapters addressed a different aspect of sports performance with a specific look to nature vs nurture.  From perceptual skills to visual acuity, to response to training, among many others.  But don't expect answers or recommendations as this field continues to evolve.

One theme throughout the book is assessing the science of the 10,000 hour rule as set for by Ericsson, et al.  While this is a huge topic, I took away a few thoughts.  No matter the genetic 'advantages' some may possess, practice and hard work are essential to athletic success.  An assessment of almost every high level athlete reveals an incredible commitment to their sport.  Chapter 2 is the story of an exception to this rule- Donald Thomas who became a world class high jumper with almost no practice.  His story is amazing but incredibly rare.  Most of the book reveals that athletic success at the highest level is only possible with an many, many hours of practice.  But genetic gifts such as body type, achilles tendon stiffness, vision, trainability among many others may allow those with a practice commitment even greater success.  And there clearly is no magic threshold for 10,000 hours of practice.  It was an average of many subjects in a study of musical success.  Practice in sports is key for success but there is no evidence to support the 10,000 hour 'rule' in sports.

Another take away point- especially pertinent to those of us caring for young athletes- is the concept of early sports specialization.  We, as physicians, have seen a trend of kids committing to one sport early and playing that sports year around.  We believe that such specialization has led to an increasing number of injuries as well as a different type of injuries (similar to those seen in older athletes).  Epstein makes several interesting points based around the following concept: near elite athletes invest more hours of practice compared to elite athletes until the mid- teen years.  At that point, the hours invested by the elite athlete increases.

1) Elite athletes may simply be gifted and not need that additional early practice

2) Future elite athletes may decrease their practice commitment in the midteen years in response to the realities of their sport or the affect of body changes (puberty).

3) Early specialization may actually be harmful to some athletes  (i.e., the near- elite) leading to a teenage decreased performance (the speed plateau in track athletes is one example)

4) Early specialization clearly decreases the opportunity to experiment with other sports that may actually offer a better chance of success.  Steven Nash, one example, played soccer primarily and only later switched to basketball.  

There are many, many other interesting stories and science facts throughout the book.  I recommend it highly.

Charles A. Goldfarb, MD

My Bio at Washington University

Anterior Cruciate Ligament Tears in Young Athletes

By: Matthew Matava, MD
Washington University Orthopedics

The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments in the knee. A ligament connects a bone to another bone. The ACL is instrumental in providing rotational stability to the knee during cutting, jumping, or pivoting activities. A young athlete who injures his or her ACL typically does so while cutting or pivoting without direct contact from another player. Girls are up to eight times more commonly injured than boys at all levels due, most likely, to differences in protective muscle firing patterns of the thigh muscles in response to a forceful stress on the knee.

Figure 1. MRI of the knee showing a torn ACL

An ACL tear is usually associated with an audible ‘pop’, an inability to continue play, and knee swelling within 6 hours. Young athletes will injure other structures in the knee, such as the meniscus cartilage, approximately one-half of the time. The injury is accurately diagnosed by the characteristic injury history, a careful physical examination, and usually an MRI, which stands for magnetic resonance imaging. This highly accurate test is able to obtain internal images of the knee with a high degree of accuracy, without exposure to radiation (Figure 1).

Figure 2. Surgical view of a torn ACL being probed

Most young athletes with an ACL tear elect to have the torn ligament reconstructed in order to prevent recurrent knee instability. Surgery is usually delayed 3-4 weeks from the time of injury to allow any knee swelling to subside and to improve the knee’s range of motion. Surgery to reconstruct a torn ACL takes approximately one hour to complete and is usually done as an out-patient under a general anesthesia (Figure 2). Care is taken in growing children not to injure the growth plates around the knee during the surgical procedure. A graft taken from another tendon around the knee is used to replace the torn ACL without any significant consequences (Figure 3). Any other injuries that are present can also be addressed at the same time.

Figure 3. Surgical view of reconstructed ACL graft

Physical therapy is very important after surgery to allow full return to normal knee function. Children require crutches to walk for up to six weeks following surgery. Young athletes are progressed through a specified sequence of exercises to regain knee motion, strength, and the ability to run, jump, and cut. Most children are able to return to sports approximately six months following ACL surgery with success rates topping 90%.



What was once an injury that doomed an athlete to a premature discontinuation of sports, an ACL tear can now be effectively and safely treated with a high likelihood of success in returning to high-level sports and other activities.

Should my Child be Lifting Weights?

By: Terra Blatnik, MD
Washington University Orthopedics

In an era where CrossFit has become common place and the pressure continues to mount in youth sports, this is a question that most parents may have on their minds: “Should my child be lifting weights? Is it safe for my child to be lifting weights?”

Strength training is the term that we use in sports medicine for weight lifting and other similar activities. In adults, strength training has been found to have obvious benefits that include improvements in cholesterol and cardiovascular health. Kids may have similar benefits and it may also improve their bone health as well.  It can improve overall strength and appropriate training programs may lead to some benefit in acquiring sports skills.  

The biggest concern is safety in strength training. We don’t want our kids to get injured while participating in weight lifting or to affect their growth in a negative way. In both cases, if done in a supervised setting, these injuries and bone issues can be avoided. Most injuries with strength training occur at home in an unsupervised setting. These are typically muscle strains which could be avoided if done under appropriate supervision. 

Before beginning any type of exercise program, kids should be evaluated by a physician to make sure that it is safe. Once this has been completed, it is important for parents to find a well supervised program with adults that understand strength training in children. They should be well-versed in appropriate lifting techniques and know what limitations kids should have.  

The American Academy of Pediatrics recently made some recommendations regarding strength training in children that provide some good rules to follow. Kids should not begin any type of strength training until they are about 7-8 years old. At this age, they have enough control and balance to handle lifting weights. Programs should focus on light weight and high repetition lifting. Olympic lifting or maximum weight lifting should be avoided until kids are skeletally mature (at least 14-15 years in girls and 16-17 years in boys). Using one’s own body weight is another way that kids can participate in strength training and further minimize the risk of injury. These types of exercises include squats, lunges, burpees, push-ups, and pull-ups. Light weight resistance tubing can also be used in strength training with minimal risk. Every session should include a 10-15 minute warm up and cool down. Strength training should just be one part of an exercise routine for kids—they should also be active in cardiovascular exercise (running, swimming, jogging, etc) and sports specific training.      

Following these basic guidelines should allow safe strength training for kids and ease parental worries about injury.      

Football and the Young Athlete

By: Matthew J. Matava, MD
Washington University Orthopedics

American tackle football has become one of the most popular sports in the United States replacing baseball in the minds of many Americans as the “national pastime”. Approximately, 2.8 million children age 6 to 14 play organized youth tackle football and another 1.3 million play at the high school level, making it among the most popular youth sports in the U.S.

Despite the millions of children and adolescents who gain the physical, social and psychological rewards that youth football provides, many parents and other interested adults continue to ask, “Is youth football safe?” This seemingly simple question is one that does not have a simple answer. Parents and administrators are debating this openly – a testament to the major shift in public sentiment recognized over the past three years. While no sport is perfectly safe, the question is whether it can be made relatively safe and if the long-term consequences of any sport are worth the risk. It may surprise parents to know that at the youth level, organized football among 5 to 15 year-olds has 12% fewer injuries per player than organized soccer in the same age range, 50% fewer injuries than bicycle riding, and 74% fewer injuries than skateboarding. In general, football-related injuries tend to vary inversely with the players’ age (and associated size and force exerted through contact) in that youth players sustain less than one-third the injuries of high school football players, less than one-fifth the injuries of collegiate players, and less than one-ninth those seen in professional football players.

Despite the perception that that the majority of football participants will eventually sustain an injury, a recent study by USA Football which included more than 60,000 individual athletic exposures (participation in a practice or game) for nearly 2,000 youth football players, found that more than 90 percent of the youth players did not suffer an injury that restricted participation; fewer than 10 percent of players incurred an injury, and of those injuries, two-thirds were minor allowing athletes to return to play on the same day.

The majority of football-related injuries occur to the musculoskeletal system, most notably the lower leg, ankle, and foot. The most common injuries among high school football players are ligament sprains. Fortunately, most of these are relatively minor and are effectively treated by nonoperative means of rest, ice, compression, and elevation of the injured area. Some ligament injuries may be season ending for a number of youth football players.

Non-orthopedic conditions are also seen in football. With summer training camps comes an increased awareness and vigilance for exertional heal illness. Young athletes account for approximately half of all heat-related injuries. High school athletes, especially males, are at the highest risk for requiring emergency treatment for this avoidable condition. Unfortunately, approximately two-thirds of football players sustaining heat illness are either overweight or obese. Other risk factors for heat illness include: practicing in the mid-day heat, wearing dark-colored uniforms, donning full pads and helmet at all times, limiting water breaks, diabetes, and sickle cell trait in African Americans. Frequent water breaks to replenish lost fluid are imperative to prevent heat-related illness. Athletes should be weighed before and after activity to replace fluid losses. An athlete should not be allowed to return to play if he has lost over 3% of his body weight following activity until those fluid losses replaced. In conclusion, football, under its current rules, will never be entirely safe and free of the risk for injuries. Therefore, it is important that there is always the proper available care to treat mild injuries with continued surveillance for more significant injuries. Instruction in proper tackling and blocking techniques, use of well-fitted equipment, and adherence to the rules of the game, are necessary means to reduce the risk for serious injury to youth players. At a minimum, first-aid training should be considered for at least one coach or league official present at all youth football practices and competitions. Given the limited resources of many youth leagues, it is imperative for those health care professionals with an interest and expertise in sports medicine to do what they can at the local level to help maintain the safety of the game so that today’s youth players can continue to enjoy all of the positive benefits of American football.