the pediatric flatfoot - Westside Podiatry Group

years of age and closure of the growth centers.Conservative treatments indude larger shoe gear, toespacers and orthotic devices.Orthotic devices are also the treatment of choice for acommon pediatric pathology known as calcaneal apophysitisor severs disease (see Figure 4). The calcaneal bone isthe only bone in the body whose epiphysis assumes thebody's entire weight prior to maturation and fusion to theprimary ossification site. The" calcaneal apophysis firstappears in females at ages four to six and in males at agesseven to eight. The apophysis may present in a unipartite,bipartite or tripartite orientation. The multiple fragmentsof the apophysis may be easily confused as fracture fragments;however, it is a normal variant. Fusion of the secondarysite to the primary calcaneal bone may be completeas early as twelve years old in females and fifteen years oldin males.Inflammatory changes to the calcaneal apophysis is acommon condition seen in children between the ages ofeight and twelve years old. Pain and inflammation at theepiphysis is precipitated by acute or chronic trauma, obesityand biomechanical abnormalities. Pathomechanicmanifestations including pes plano valgus, torsional deformities,calcaneal valgus and tarsal coalition cause excessivesubtalar joint and midtarsal joint pronation in children.Pronation creates tension from the achilles tendonand plantar fascia on the calcaneus. The achilles tendoninserts in -the posterior proximal aspect of the apophysisand the plantar fascia originates at the inferior distalaspect of the apophysis. Pronation essentially creates a tugof war mechanism between the two tendons causinginflammation of the secondary growth center. The painand inflammation is exacerbated by sporting activities,barefoot walking and pediatric obesity. Many times this iswritten off to "growing pains," but growth should not bea painful process.On examination demonstrable pain is noted on lateralcompression to the posterior aspect of the calcaneus andwith direct pressure to the lower one third of the posteriorcalcaneus. Calcaneal apophysitis is always treated byconservative means as this condition is self limited uponfusion of the epiphysis. Initial treatment includes rest andcessation of sports, heel lifts and padding. Below kneecasting is an option in resistant cases. Custom moldedorthotics are quite beneficial as they stop the traction ofthe plantar fascia and achilles tendon as well as providepadding to the sensitive heel.FIGURE 1: PLANTAR PEDAL WART FIGURE 2: PARONYCHIAFOOTPRINTS / FEBRUARY 2002 WESTSIDE PODIATRY GROUPPAGE 3