“Don’t Panic Just Yet” Normal Development of the Pediatric Foot and Lower Extremities
ORTHOTICS
K. Jeffrey Miller
One day, just after I turned five, I was playing in the front yard with my mother watching over me. While there, our neighbor Mrs. Henry, came over to visit. Mom and Mrs. Henry struck up a conversation, and as they talked, I became aware of Mrs. Henry watching me. A short time later, I heard her ask my mother if she had noticed the way I walked and ran.
My mother asked, “Why?”
Mrs. Henry replied, “Haven’t you noticed? Jeff is pigeontoed.”
My mother watched as I continued to play. She noticed what Mrs. Henry saw and went into panic mode. Before I knew it, we were at the family doctor who immediately referred us to an orthopedist in Louisville. During the orthopedic visit, I had to strip to my underwear and walk up and down the clinic’s hallway while the doctor watched me.
After he watched me walk, I was allowed to dress and the doctor returned a few minutes later to discuss his observations with my mother. He confirmed that I was pigeon-toed. With the flair of Scarlet O’Hara, my mother asked, “Oh doctor, can anything be done?”
His answer, “Cable braces.” The braces would twist my feet and legs outward to point straight while I stood or walked.
You don’t see cable braces these days. Ifyou are not familiar with them, watch the movie Forrest Gump. Forrest had a set of cable-like braces. The braces consisted of a large thick belt at the waist and steel cables were attached to the lateral aspects of the belt. The cables descended down the sides of the legs where thick straps anchored them just above and below the knees. The cables ended at the ankle where they were attached to what had to be the ugliest pair of shoes ever to exist.
I was placed immediately in the braces and wore them until sometime between the ages of six or seven. Doctor visits occurred every three to four months for reexamination and adjustment of the braces. Once I was out of the braces, I was stuck with the ugly orthopedic shoes until I reached the end of the fifth grade.
I went through grade school in those ugly shoes. For years, it was difficult to walk or run, and other children made fun of me on a regular basis.
When I think back to that time in my childhood, I often think about how the doctor responded to my mother’s question, “Oh doctor, can anything be done?” He might as well have said, “We’ll need to torture the child for several years. It’s his only hope.” To me, that was what the treatment amounted to—torture.
By the early 1980s, cable braces were seldom used because
the truth about them was finally known. The braces were a farce. Most children go through periods of being pigeon-toed during development. There was no reason to treat a normally developing child for something that isn’t pathological.
I did not have a clear understanding of this fact until early in practice when it came up in a casual conversation with my friend Joe, a medical orthopedist. We were talking about our kids, and I told him I was thankful my children had not inherited my pigeon-toed deformity and the resulting cable braces.
He chuckled and asked, “Did you wear cable braces? In the 60s or 70s?”
“Yes, I wore them for two years followed by four years in orthopedic shoes,” I replied.
He questioned me further. “You do know what the braces were for don’t you?”
“To straighten my legs,” I responded.
“No, man! They were to appease your parents. They were a placebo. America had just faced a generation of children
^For the record, children’s feet and legs do go through a series of changes as part of normal development between learning to walk and age six. 5 J
with polio, and parents would freak out about any sign that their child had a problem with his legs. Doctors would tell parents that periods of being bowlegged or knock-kneed were typical and that the child would ‘grow out of it. ’ Parents often refused to believe this or worried their child would not follow the normal course of development. The parents would then demand something be done. I bet you wore them up until age six or seven, didn’t you?”
“I wore them until sometime between six and seven.”
“Yeah,” Joe said. “Age six is the time when the legs are finally straight and the doctors would remove the braces. Abracadabra and poof! The braces had cured the problem! The doctor had saved the day. Sorry you went through that, man.”
At the end of the conversation, Joe said, “Wait just a second.” He disappeared and returned a few moments later with a copy of a newspaper article that described the phenomenon he had just explained. He related that he gave a copy of the article to concerned parents. “Some parents still panic and insist something be done for their child. I give them the article to help convince them to let their child develop normally.”
After the conversation and reading the article, I reflected back to my childhood and thought, “Well, thank you Dr.
*$%#A.”
The practice of using the braces stopped, but the medical profession is still reaping benefits from the farce. I am sure millions of baby boomers are seeing psychiatrists because of wearing cable braces during their childhood.
For the record, children’s feet and legs do go through a series of changes as part of normal development between learning to walk and age six. We will discuss the changes here to assist doctors in relaying their significance to concerned parents. Maybe this article will be the next article doctors can hand to concerned parents.
The Legs
Normal Development
Infants’ and toddlers’ legs are described as “genu varum,” which is the technical term for being bowlegged. Their legs are bowed and the feet turn in slightly (toeing-in, or pigeontoed). As the child passes through the stages of crawling, creeping, standing, and walking, the legs slowly straighten.1
By eighteen months of age, the legs have straightened and the feet have begun to point outward (toeing-out).1
Between eighteen months and thirty months, the legs are described as “genu valgum,” which is the technical term for being knock-kneed. While the legs have undergone another change, the feet remain in a toed-in position.1
As growth continues, the feet gradually rotate from toeing-out to toeing-in. The child is now knock-kneed and pigeon-toed. This stage is often referred to as “protective toeing-in.” The position is protective as it shifts the body’s center of gravity over the center of the feet. This helps reduce or prevent fatigue and foot strains.2 This was the posture of my legs when our neighbor mentioned to my mother how I ran and walked.
Protective toeing-in gradually disappears, and by age six the legs are straight and the feet show a mild degree of toeingout. Legs should remain in this posture as growth continues into adulthood.
The postural transitions described here are the norm. They do not indicate a problem. Atme problem would be indicated by failure of the transitions to occur, which is a situation that should always be investigated.
Another situation that would warrant investigation is if a child failed to reach the normal posture of straight legs with mild toeing-out by age six.
The Feet
Babies and toddlers have chubby feet that are very round in appearance. The rounded appearance gives the impression that the medial or primary arches of the feet are absent. 3
In reality, the arches are present and hidden by pads of fat between the arches and the bottom of the feet. The fat pads fill the depressions usually created by the arches, giving a rounded appearance to the center of the feet. As a child ages, the fat pads slowly disappear. They are completely gone by age three, and the medial arches are then evident.
If medial arches are not evident by age three, the child should be evaluated to determine the reason. If the feet are flat, it should be determined if the flat feet are flexible or rigid. This is determined by grasping the foot and attempting to move the foot in the area of the medial arch.
If the feet/arches are movable, the flat feet are flexible. If the feet/arches ai e not movable, the flat feet are rigid. Professional intervention may be necessary at that point. Flexible flat feet usually respond to treatment—typically orthotics. Rigid flat feet do not respond to treatment as well as flexible flat feet, but should be supported to prevent further issues.
The feet go through periods of toeing-in, toeing-out, and being straight. It must be stated though that “straight” does
not mean perfectly straight. “Straight” means the toes will point slightly outward. Normal toeing-out should be between five to 18 degrees, a measurement known as the Fick angle.1
Growth Spurts
The period between birth and age six is a time of significant growth for a child. A second significant growth period occurs between ages twelve and sixteen. During these periods, children should be examined closely to ensure normal patterns of growth are occurring.
The second growth spurt is also important in the detection of scoliosis.4 Periodic screening of the legs, feet, and spine must occur during this time period.
A Final Word
It must be noted that there are pathological conditions that cause changes in the posture of a child’s legs and feet. Still, changes caused by these pathologies are not as common as changes that occur naturally. Differentiation between pathological and natural changes is another reason that routine assessment of a growing child’s legs and feet is necessary.
Methods of assessing the legs and feet vary greatly, and the most common methods include observation, postural assessment, foot scans, and gait assessment.
Parents should seek a healthcare provider who takes advantage of these methods to assure a child is developing normally. This should begin at an early age, as intervention should start immediately, if necessary.
I hope that the information provided here will educate healthcare providers so they may ease the minds of parents. This will help avoid unnecessary panic by parents that could have long-lasting physical and emotional effects on their children.
Sources
1. Magee, I)., Orthopedic physical assessment, 5 th ed., St. Louis, Saunders-Elsevier, 2008.
2. Behnam, R, Mortazavi, J, Rotational deformities of the lower limb in children. Iran Journal of Pediatrics, Vol. 17, No. 4 pages 393-397, 2007.
3. Chong, A., Is your child walking right? A parents ’guide to little feet. Wheaton, Wheaton Resource Corporation, 1986.
4. Yochum, T, Rowe, L., Essentials of skeletal radiology, 3rd ed., Philadelphia, Lippincott, Williams and Wilkins, 2005.
K. Jeffrey Miller, DC, MBA is a chiropractic orthopedist in Roanoke, VA, Dr. Miller is the author of Practical Assessment of the Chiropractic Patient, Orthopedic and Neurological Examination in a Flash, Chiropractic Medicare Documentation Self Inventory and The Road to Happiness is Always Under
Construction. He can be reached through his website examdoc.com
