Pediatric Podiatry - Milestone Markers

Caring for your baby’s feet is much like caring for the rest of their body with periodic checkups and milestone markers to assess early development. As long as the baby’s feet are healthy at birth most newborns won’t require special care for their feet.

Good milestones for your child’s visit are 18 months, 3 years and 5 years of age. 

When your baby starts to walk gripper socks or soft-soled shoes to protect their feet are best inside the house. Outside, put them in a good quality children’s shoes, lace or Velcro, to give them support and protection. If foot problems run in your family it is especially important to have your child examined by a podiatric specialist. Certain foot deformities are inherited. Early intervention can often prevent problems from carrying on and worsening into adulthood leading to future lower extremity, knee and hip pathology.

By the age of 18 months your child should be seen by a podiatrist who will be able to clinically exam your child’s feet and ankles, evaluate their biomechanics and gait, recognize potential problems and offer guidance and recommendations to ensure the proper care and development of your child’s feet.

Five years is a key milestone in children’s foot health because their feet transition from soft, flexible, and fat-padded structures into more rigid, defined, and adult-like shapes. By this age, the foot arch of a most children becomes more developed and the cartilage that makes up a toddler's foot begins to harden into bone, forming a more rigid, mature structure. In some cases because arches do not completely develop until around age 8. For this reason foot health exams for children should generally occur annually from the age of three to monitor growth and screen for potential problems. Earlier and more frequently should recognized problems require treatment.

Flat feet

One of the common concerns that many parents have about their children’s feet is flat feet (pes planus) or the absence of an arch. A baby’s foot can be fat, flaccid, floppy or flexible, but between 18 months and 3 years of age, and by then, the arch should begin to form. Pain, tiredness in the feet, or ankle rolling are symptomatic of pediatric flatfoot.

Upon clinical examination, if there is evidence of compensatory changes resulting from pronation associated with pes planus that significantly affect development in the muscles, tendons and bones of the foot, create pain or influence your child’s gait your podiatric physician may recommend prescription children’s orthotics.

In-Toeing

Another concern many parents have as their child learns to walk is a rotational problem commonly known as in-toeing. In-toeing is a gait variation, not typically considered abnormal in infants and young children however it may be significant and does merit evaluation. Most in-toeing cases tend to present as asymptomatic (no symptoms) however any noticeably functional limitations such as the following should be evaluated as issues with tripping, stability and balance and lead to more serious developmental problems.  Consult with your podiatric physician if you have any concerns or note any of the following.

• Pain or Limping: The child complains of hip, knee, or foot pain.

• Asymmetry: One foot turns in significantly more than the other.

• Severe Tripping: The gait causes frequent falls or impairs movement.

• Stiffness: The foot or leg feels rigid rather than flexible.

There are several causes of in-toeing with different levels of treatment. It is important that the cause of in-toeing be diagnosed so consultation with a podiatrist is always recommended. He/she will then advise you as to whether your child requires treatment.

The most common cause of in-toeing is internal tibial torsion, when the tibia (shin bone) has an internal twist and turns inward. Although it is common in infancy and childhood with a varied etiology (cause), it requires diligent observation by parents and on-going physician evaluation to determine whether it normally improves resolving on its own. To rule out any underlying structural problems diagnostic imaging may be ordered to determine if there are issues associated with the hips, legs, or feet.

The child should be monitored every few months for signs of improvement and to ensure no secondary problems develop.

W-Sitting

Sitting in the "W" Position

A series of rotational changes in the lower extremities occur as children progress from crawling to standing to walking. There are certain patterns of behavior that influence and may delay natural de-rotation that results in in-toeing. What causes the delay in de-rotation? There are a few causes but by far the most common would be when the child adopts sleeping and sitting habits referred to as W-sitting.

W-sitting is when a child is sitting on their bottom with both knees bent and their legs turned out away from their body. If you were to look at the child from above their head, his or her legs will look like the letter “W”. For many children this is the way they sit without even thinking about it. Oftentimes the added stability of this position allows them to play without falling over so it becomes their preferred way of sitting. Problems occur when children sit in this position for an extended period of time creating potential rotational problems, muscle development and issues with balance and laterality. There are certain behavioral changes parents can make at home that encourage other ways of sitting that can be helpful to correct this.

Toe Walking

Toe walking is a condition where a child consistently walks on their toes or the balls of their feet instead of using their entire foot to walk. It is is commonly observed in children who are just beginning to walk. Most children learn to walk normally by the age of three. If toe walking persists past the age of two or three, it could be of concern as it may delay developmental milestones, affect balance and stability, indicate underlying medical conditions, and lead to long-term complications if left untreated.

Toe walking is idiopathic, meaning that the exact cause is not known. Different factors may contribute to toe walking. If your child is still toe walking by the age of three, it is recommended that they be examined by a podiatrist. Exercises can be helpful and if necessary can be discussed with your physician.

Pediatric Podiatry - Milestone Markers

Dr. Marasco is a Diplomat of the  American Board of Foot and Ankle Surgery, the American Board of Quality Assurance and Utilization Review - Physician, Fellow American College of Podiatric Sports Medicine and Fellow of the American College of Foot and Ankle Surgeons.