Pediatric Page (Continued)
Ingrown Nails
Ingrown toenails are usually caused by abnormal pressure on the side of the nail causing the nail to deform. This abnormal pressure is often caused by an abnormal walking pattern that causes the foot to collapse outward resulting in walking off the side of the toes rather than the tips of the toes as was designed. The deformed nail can literally grow into and puncture the skin - hence the name Ingrown Nail. If the nail punctures the skin, bacteria around thnail can get into the body and cause an infection (Paronychia). The body will try to wall off any infection in an attempt to keep it from spreading throughout the body. This localized infection is called an Abscess. The infection will usually not clear completely until the foreign object - the ingrown nail - is removed.
Often an ingrown nail is present for quite some time before becoming painful. Kids in particular like to let the problem fester for weeks, if not months, in fear they will have to see a doctor. Parents will often try to correct the condition at home. This 'bathroom surgery' can actually make the condition worse. We've seen some very impressive (and some not so impressive) attempts at self treatment whether it's "cutting out" the painful corner of the nail multiple times or cutting a 'V' in the nail. This 'V' technique, for the record, does not work and is not recommended. The problem is that the skin by the side of the nail quickly re-grows next to the nail and the corner becomes ingrown further back until it is just too painful to "cut out".
Ingrown toenails can be very painful and if not treated early, may develop a significant infection. At Northeast Foot & Ankle Specialists, PC we make sure that patients with ingrown toenails are seen right away. Let our receptionist know that your child may have an ingrown toenail and we will get you in on the same day or, if you cannot make it, the next business day. Ingrown toenails usually resolve very quickly after the ingrown portion of the nail is removed either by trimming the nail corner, or in some cases, removing the edge of the nail back to the cuticle. Usually, a local anesthetic is used to lessen the discomfort.
We treat hundreds of kids with ingrown toenails every year and we take great pride in our ability to make the care of an ingrown toenail a nearly painless procedure for our patients -- especially kids. If your child's toe is tender we ensure that the toe is completely numb before taking care of the nail problem. We even 'numb up' the skin with a cold spray before giving a local anesthetic. The most common statement we hear after taking care of an ingrown toenail is "That was easy - I wish I hadn't waited so long!" Some kids will record the procedure and show it on YouTube. In addition, we usually only have to remove a very small portion of the nail resulting in a normal appearance after it has healed.
Tips for Preventing Ingrown Toenails
- Cut toenails straight across
- Don't cut toenails too short
- Don't pick your toenails or tear at the corners
- Wear shoes with plenty of toe room
- Avoid wearing tight socks or pantyhose
Plantar Warts
Warts (verrucae) are caused by a virus that generally enters the body through small nicks, blisters or abrasions in the skin. Warts can appear on all aspects of the foot from top to bottom and heel to toe. When they occur on the soles of the feet they are known as plantar warts - 'plantar' being the bottom of the foot. Due to the amount of pressure that is put on the feet in the course of a day, plantar warts can become quite painful. Teenagers between the ages of 12 -- 16 are most commonly infected by warts, but they can occur at any age. Warts are also often contracted by walking barefoot on dirty surfaces. The virus thrives in warm, moist environments like showers and swimming pools. Be sure to look at all the feet in your family as warts can be contagious and it is not uncommon to see siblings requiring treatment.
If you suspect that you or a family member has a plantar wart, see a podiatrist to get a correct diagnosis and treatment plan. Over-the-counter wart preparations rarely work on plantar warts due to skin thickness and depth of the lesion. Treatments may include the use of a high concentration acid formula or surgical removal performed under local anesthesia to safely remove the wart. Prescription topical and oral medications may also be used to stimulate an immune response to the virus. Clinical studies have shown oral medications such as Cimetidine, when dosed appropriately, to be quite effective in children under the age of 18. We also use Vitamin A plus Zinc. Rarely is surgery necessary to remove a wart. At NEFAS we have a Pulse Dye Laser in the office which is a state-of-the-art non-invasive and mildly painful treatment requiring no after care. This technique is usually effective after 3-4 treatments spaced 2 weeks apart.
Hyperhydrosis and Bromhydrosis (Sweaty Smelly Feet)
We all know that kid who clears a room when he removes his shoes. He is likely suffering from hyperhydrosis and bromhydrosis. The real question is who is truly suffering when those shoes are off? There are more sweat glands per inch of our feet than anywhere else in the body and their function is to keep the skin moist and therefore supple. The glands secrete all the time, not just in response to heat or exercise, as elsewhere in the body. Hyperhidrosis, or excessive sweating, is caused by over-active sweat glands on the bottom of the foot. Hyperhidrosis is especially common in adolescence when hormonal changes and emotional/physical stresses are prevalent.
Left untreated, hyperhidrosis can lead to athlete's foot, blistering, skin maceration and painful calluses on the soles of the feet. Of greater concern to most, a big side effect of this condition is unpleasant foot odor - known as Bromhydrosis. This is caused by bacteria on the skin, breaking the sweat down which releases an offensive smell.
Using a daily over-the-counter antiperspirant on your feet can reduce the moisture and odor. Both spray and roll-on products are effective. Prescription drying agents are available when necessary. It is also very important to change socks regularly and air out shoes by removing the shoe liners at night. Train your child early about the importance of socks in protecting feet. At Dr. Bregman's office we offer several products that can significantly reduce, if not eliminate, the associated odor. Your child will no longer worry about clearing a room when they remove their shoes.
Athletic Injuries in Kids
All parents know that children take to sports like ducks to water. Almost as soon as they start to walk, they're chasing balls, swinging sticks, and running races against their real or imaginary friends. Children's sports used to mean baseball, basketball, or football. Times have changed. Soccer has leapt onto the youth sports scene, as have wrestling, tennis, and lacrosse with older children. The starting age for training in individual sports such as swimming, skating, track, and gymnastics grows younger every year - the image of Tiger Woods hitting golf balls at age 4 comes to mind.
Injuries may involve the bones, ligaments, tendons, or other soft tissue structures in the foot and ankle. Many injuries are unique to certain sports, whereas others are seen in all types of activity. Injuries can occur suddenly (acute) such as fractures and sprains or develop over time (chronic) like stress fractures and tendonitis. Each type of injury has a specific treatment. At Dr. Bregman's office a child athlete must pass the "5-Step Test" before safely returning to active play.
5-Step Test to Safely Return to Sport
- Walk/run with full range of motion.
- Walk on tiptoes without pain.
- Jump on both feet without pain.
- Hop on the affected foot without pain.
- Demonstrate balance by performing single-leg stance on the affected side.
Sever's Disease/Pediatric Heel Pain
Don't be alarmed by its name. Sever's disease is not contagious and not terminal. It occurs in children when the growth plate (which is the growing part of the heel) is injured. The foot is one of the first body parts to grow to full size. This usually occurs in early puberty and is common among child athletes. During development, bones often grow faster than muscles and tendons. As a result, muscles and tendons become tight. The heel area becomes less flexible. During weight-bearing activity, the tight heel tendons may put too much pressure at the back of the heel where the Achilles tendon attaches. This can injure the heel and cause an inflammation of the growth plate known as calcaneal apophysitis - or Sever's disease.
Your child is most at risk for Sever's when he is in the early part of his growth spurt in early puberty. Sever's disease is most common in physically active girls and boys 8-10 years old and 10-12 years old, respectively. Soccer and baseball players (those wearing cleats) and gymnasts often get Sever's disease, but children who do any running or jumping activities are also at risk. Sever's disease rarely occurs in older teenagers because the back of the heel has typically finished growing by the age of 15.
In Sever's disease, heel pain can be in one or both heels. It usually starts after a child begins a new sports season or a new sport. Your child may walk with a limp. The pain may increase when he or she runs or jumps. He or she may have a tendency to tiptoe. Your child's heel may hurt if you squeeze both sides toward the very back. This is called the 'squeeze test'. Your podiatrist may also find that your child's Achilles tendons have become tight.
Treatment of Sever's is always conservative. First, your child should cut down or stop any activity that causes heel pain. Apply ice to the injured heel for 20 minutes 3 times a day. If your child has a high arch, flat feet or bowed legs, your podiatrist may recommend orthotics, arch supports or heel cups. Your child should never go barefoot with this condition.
If your child has severe heel pain, anti-inflammatory medications may help. It is important that your child perform exercises to stretch the hamstring and calf muscles, and the tendons on the back of the leg. Both legs should be stretched, even if the pain is only in one heel. For specific stretching instructions, consult your podiatrist.
With proper care, your child should feel better within 2-8 weeks. In rare cases, your child might have to wear a below-knee cast for 2-6 weeks to allow the growth plate to heal. No long-term problems have been linked with Sever's disease. Sever's disease may be prevented by maintaining good flexibility while your child is growing. Good-quality shoes with firm support and a shock-absorbent sole will help. Your child should avoid excessive running on hard surfaces. If your child has already recovered from Sever's disease, stretching and putting ice on the heel immediately after activity will help keep your child from developing this condition again.
Sever's disease is the most common, but not the only cause of pediatric heel pain. We recommend you schedule an appointment with a podiatrist for a thorough evaluation of your child's condition.
Pediatric Sprains and Fractures
A sprain is an injury to a ligament that attaches to bone and a fracture is a break in the bone itself. Sprains are rare in children because the ligaments are stronger than the growth plates. The growth plate is the part of the bone from where normal growth occurs and is most frequently injured. When sprains do occur, some form of immobilization (cast or brace) is indicated in order for the ligaments to heal at their normal length. If the ligaments heal in a "lengthened" position, it predisposes the child to repeat sprains.
A fracture in a child's foot or ankle can be very different from a fracture in the same location in an adult. Occasionally there can be a disturbance of the normal growth from a fracture (growth plate injury) resulting in a bone shortening or angulation. X-rays will generally show if a fracture involves the growth plate. There are five different patterns of growth plate injuries observed on x-ray - each may have a different prognosis. Occasionally the initial x-rays will not show a fracture even when one is present, which causes confusion for parents.
Most often pediatric fractures are treated conservatively with immobilization/casting. If the fracture is displaced, the alignment may need to be improved with manipulation of the fracture. Manipulation or reduction may be done closed (without visualizing the bone directly) or open (with direct visualization, manipulation and fixation of bone with pins, plates or screws) depending on severity, timing, and location. Both techniques will require some form of sedation and may take place in the operating room. The podiatrist will advise you as to which option is best for your child.
Orthotics / Arch Supports
Custom-made foot supports that are worn under your heel and the arch of your foot are referred to as orthotics. These devices are molded to be anatomically matched to your foot and do more than just provide support. Custom foot orthotics when properly prescribed by a qualified podiatrist, allow the muscles, tendons and bones of the feet and lower legs to function at their highest potential. This is most important in children when the musculoskeletal system hasn't fully developed. Orthotics can also help to stabilize unstable joints, slow down deformities, reduce pressure on painful aspects of the foot and, improve overall quality of life. Childrens orthotics tend to be more aggressive in an effort to obtain maximum control and guide future growth.
How do you know if the use of orthotics is right for your child? If there is an obvious imbalance that causes such symptoms as flat feet or high arches, or there are external misalignments such as "knock knees", "bow knees", in-toeing, or out-toeing, then your child is probably a good candidate for orthotics. If your child participates in an activity that places stress on their feet, orthotics could be beneficial. The best way to find out if orthotics can help is to make an appointment with a podiatrist for an exam.
A true custom orthotic should be prescribed by a podiatrist who has thoroughly examined your child's feet, posture and gait. Be cautious of "foot comfort stores" or kiosks offering orthotics at reduced prices. The knowledge and training of the individual treating your child is usually directly related to the success of their treatment. If orthotics are not necessary, a podiatrist will tell you so. If orthotics can help, Northeast Foot & Ankle Specialists, PC will use the best possible techniques to create appropriate state-of-the-art orthotics designed specifically for your child's foot condition. We can adjust and repair orthotics in the office to ensure that the orthotics are working perfectly and feeling comfortable for years to come. It is important to note that orthotics are not always the answer as they cannot change foot structure; just support the foot.
Final Thoughts
We hope the information in this publication has been helpful. Studies have shown over and over again that feet often get ignored when it comes to the overall care of the body. We know your pediatrician works very hard to care for your child and is highly educated, but they cannot do everything. When it comes to feet, a proper evaluation by a podiatrist who specializes in pediatrics like we do is the best option for your child.
As we have illustrated in this book, children and adolescents experience a variety of foot and ankle problems. Some problems may be evident at birth and others don't become obvious for some years. If you feel that your infant, toddler, or adolescent has something that doesn't look quite right, then get it checked. It may save them a lot more trouble as an adult if treated sooner.
We know that making an appointment to see a doctor isn't always the easiest thing to do, but with knowledge and understanding you can see that the podiatrists at NEFAS offer many treatments that can greatly improve your child's quality of life. Don't let your child live with foot, ankle or leg pain. Most problems can be treated with conservative and pain-free treatment.
Dedicated to Your Foot and Ankle Health,
Dr. Peter J. Bregman
