A 6-year-old male came to clinic for his health supervision visit. His mother had no concerns but had noticed some intermittent mild limping. He denied any problems and his mother denied any fever, muscle aches, back pain, or trauma. She thought it had been occurring for a few weeks or “since the spring started.” The past medical history was negative for any trauma, orthopaedics or neuromuscular problems. The review of systems was negative.
The pertinent physical exam showed a healthy-appearing boy with normal vital signs and growth parameters in the 75-90%. His musculoskeletal examination was normal except that he had calluses on the lateral 5th metatarsalphalyngeal bones of both feet and along the edge of the heels.
The diagnosis of a healthy male was made. The pediatrician looked at the child’s shoes and noted that they seemed worn. When placing them against his feet they were obviously too small. His mother said that they would look into getting new shoes right away. “I’m also going to check his soccer shoes. I bet those are small too,” she said.
Probably the most common foot problem is foot pain or skin problems. This can be due to chronic and acute trauma, mobility issues, normal development, activities and footwear.
Common foot problems include:
- Acute trauma is probably one of the most common reason patients and families seek care for is pain after acute trauma. Children prior to full puberty with acute trauma may have a growth plate fractures or Salter-Harris fractures which can be reviewed here.
- Apophysitis and tendonitis are common overuse injuries where there is irritation of the tendon and its insertion points. Chronic overuse can also lead to fracture. A review can be found here.
- Hallux valgus or bunion is caused mainly by restrictive footwear. It is very common in patients with Down Syndrome. A review can be found here.
- Plantar fasciitis is pain in the plantar area with its dense connective tissues due to overuse. Stretching exercises, a heel cup, supportive shoes and nighttime splinting can help with the pain. It can be a slow heaing process though. A review can be found here.
- Pes Planus or flat foot is a common presentation in children and is the absent or diminished longitudinal medial foot arch. Flexible flat feet occur in children < 6 years and should be painless. History of pain makes this diagnosis less likely. A review can be found here
- Plantar warts caused by viruses can be irritating and quite painful for patients. There are numerous treatments including debridement, local acid treatments or cryotherapy as common mainstays. There are potential complications that need to be considered though. A review of treatments can be found here. A review of potential cryotherapy treatment problems can be found here.
- Tinea pedis and onychomycosis are common skin and nail infections due to exposure to humid environments and exposure to fungal infections, including that of shoes themselves. Treatment is increased air exposure and topical or oral anti-fungal medications. Prevention measures can be reviewed here.
- Immersion injury – most people are well aware of experiencing wrinkled skin after being exposed to water due to hyperhydration of the plantar stratum corneum. Immersion injuries occur after extended or repeated exposure to water in warm or cold environments. Treatment is mainly preventative but severe problems can occur. A review can be found here.
Corns and calluses are other common foot problems. Both are thickened skin caused by friction or pressure. It is the skin’s protective mechanism to protect the underlying tissues. They are usually due to increased activity, ill-fitting shoes or anatomic foot problems. Calluses are not painful usually unless they themselves are injured (e.g. cracked skin) and are located in places of high movement and pressure (such as hands and feet). Corns are smaller than calluses. They have a hardened center and can be painful when palpated. They are located in non-pressure areas such as between toes.
- Decreasing pressure or friction. Using appropriate footwear along with socks can decrease the friction. Socks can also wick moisture away.
- Padding of the area to allow it to heal
- Over the counter or customized orthotics and shoes to decrease pressure and friction
- Salicylic acid, urea and similar products can soften and diminish the thickened tissue
- Scalpel debridement is also sometimes used
Shoes are judged by their form, fit and function with fit usually governing how they function. Therefore fit is very important. In a systemic review, it was estimated that 63-72% of people had improperly fitted shoes. A study of children with Down Syndrome found shoes that were too narrow.
Proper footwear should:
- Be usable right out of the box. It should not need to be “broken in.”
- Shoes should be fitted when feet are the largest which is at the end of the day. They should be fitted while weight-bearing on both feet. This allows the foot to spread. Walking or running can also cause the foot to spread and shoewear should be tested doing these activities as well.
- Shoes should fit snugly and not slip off. The heel needs to be able to move but should fit snugly
- Length should be ~ 10 mm from the longest toe for general shoes with athletic shoes up to 1 inch. Width should allow for adequate space across the entire ball of the foot (usually < 10 mm extra space).
- If orthotics or other appliances are used, they should be in place while fitting shoes as they will change the fit.
- Specialty shoes usually need activity/occupational specialists to fit such shoes. For example, pointe shoes for ballet dancers or skates for skaters. A review can be found here.
Foot professionals may characterize general foot and toe morphology as Egyptian (first toe is the longest), Greek (second toe is the longest), and square (first and second toes are of equal length). These can be important as most children’s shoes are developed on adult foot templates which are developed usually from square toed morphology. Children’s feet grow faster than most parents realize and they need new shoes often. Toddler and young preschoolers may need new shoes 3-4 times/year, those 4-6 years about 2 times per year and those 6-12 years about 3 times per year. Adolescents may need them more frequently depending on age of puberty.
Questions for Further Discussion
1. What are the most common foot problems in your clinic?
2. What are your favorite treatment choices for corns and calluses?
3. What causes limping? A review can be found here
- Disease: Corns and Calluses | Foot Injuries and Disorders
- Symptom/Presentation: Foot Pain
- Specialty: Dermatology | Orthopaedic Surgery and Sports Medicine
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Corns and Calluses and Foot Injuries and Disorders.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Buldt AK, Menz HB. Incorrectly fitted footwear, foot pain and foot disorders: a systematic search and narrative review of the literature. J Foot Ankle Res. 2018;11:43. doi:10.1186/s13047-018-0284-z
Becker BA, Childress M. Common Foot Problems: Over-the-Counter Treatments and Home Care. AFP. 2018;98(5):298-303.
Gonzalez Elena ML, Cordoba-Fernandez A. Footwear fit in schoolchildren of southern Spain: a population study. BMC Musculoskelet Disord. 2019;20:208. doi:10.1186/s12891-019-2591-3
Corns and Calluses Cedars-Sinai. Accessed November 23, 2021. https://www.cedars-sinai.org/health-library/articles.html
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa