Common Disorders
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Did you know the foot has 28 bones, 37 joints, 107 ligaments, 19 muscles, and numerous tendons? These parts all work together to allow the foot to move in a variety of ways while balancing your weight and propelling you forward or backward on even or uneven surfaces. It is no wonder that most Americans will experience a foot problem that will require the care of a specialist at one point or another in their lifetime.

There are a number of different causes of lumps and bumps on the bottom of the foot. Working from the toes to the heel:

1. Lumps and Bumps on the Bottom of the Big Toe

A painful lump may be found on the bottom of the big toe. This condition often presents itself as a hard callused area. Sometimes a hard lump may be felt beneath the callused area. The most common cause of this condition is a limitation of movement of the big toe joint while walking. If there is limitation of movement at this joint, then the big toe cannot bend upward as the heel comes off the ground while walking. As a consequence, there is excessive force placed on the bottom of the big toe and an enlargement of the bone in this area will occur secondary to the pressure. Another cause is the presence of an extra bone or piece of cartilage in the area. However, it is the limitation of movement in the big toe joint that causes the area to become enlarged and painful.

People who have diabetes must watch these areas closely. Over time, the excessive pressure can cause this area to break down and ulcerate. One way to check to see if there is a limitation of movement of the big toe joint is to perform the following test. While standing on a flat surface, have another person try to bend the big toe upward. The joint that must move is the joint where the toe attaches to the foot. There is a joint in the middle of the big toe and this is not the one you are checking. If the big toe joint cannot be bent upward then a limitation of motion exists. Testing the movement at the joint without putting weight on the foot will give a false impression as to the available movement at the joint while you are walking. This limitation of movement of the big toe while walking can, over, time create an arthritic condition in the joint. A bony mass may then form on the top of this joint as a result of jamming in the joint. This condition is called hallux limitus or hallux rigidus. Treatment for the painful lesion in the bottom of the big toe joint consists of using functional foot orthosis to correct the functional limitation of the big toe joint motion or may consist of surgical correction of the hallux limitus. Rarely is surgery to remove only the lesion on the bottom of the toe alone, successful, because the cause of the initial problem still exists.

Knee pain in children may be caused by a variety of conditions. Some of these conditions may be rare but can be quite serious in nature. Knee pain in children should be evaluated by your doctor.

Osgood-Schlatter's Disease

A common cause of knee pain in a growing child is injury to a growth plate in the front of the knee. This may be accompanied by swelling in the area. This condition is called Osgood-Schlatter's disease. It occurs most commonly in children between the ages of 10 -14. It is often associated with playing sports and aggressive bicycle riding. It is felt that the condition is primarily caused by an abnormal pull of the tendon that attaches into the painful area from the kneecap. This tendon is called the patellar tendon.

Professor Gavriil Abramovich Ilizarov graduated from medical school in the Soviet Union in 1943, near the end of World War II. After graduation, he was assigned to practice in Kurgan, a small town in western Siberia. He was the only physician within hundreds of miles and had little in the way of supplies and medicine. Faced with numerous cases of bone deformities and trauma victims due to the war, Professor Ilizarov used the equipment at hand to treat his patients. Through trial and error, with handmade equipment, this self-taught orthopedic surgeon created the magical combination that would cause the bones to grow again, similar to the adolescent growth state. Thus the Ilizarov technique was created.

For almost 45 years, Ilizarov and his co-workers have been perfecting their apparatus and helping individuals with severe orthopedic abnormalities. Reports of dwarfs made taller, and birth defects corrected were first observed in Italy, and then presented in the United States where Professor Ilizarov's technique met initial skepticism.

First metatarsal neck osteotomies are known by various names based on the individual who first described the procedure (e.g. Austin, Reverdin-Green, Kalish-Austin). Regardless of the procedure, the goal of all these procedures is the same, to remove the bump and realign the joint. The first part of all bunion procedures involves removing the bump of bone from the side of the 1st metatarsal head. This is performed in a manner so as not to damage the viable part of the joint and not to leave any irregularities of bone that can cause future irritation in shoes. Once this is completed, the podiatric surgeon will create an osteotomy (bone cut) through the first metatarsal that will allow shifting the bone and realigning the joint. Depending on the type of osteotomy, the actual shape of the bone cut can vary. In the case of the Austin bunionectomy, the bone cut is V-shaped with the "V" sitting on its side and the tip of the "V" pointing toward the joint. When this cut is completed, the head of the metatarsal and joint is shifted toward the 2nd toe. In this way the bone and joint are repositioned in a more normal position. The Reverdin-Green osteotomy is made in a similar location but is trapezoidal in shape rather than V-shaped. Both these procedures are stable bone cuts and provide good correction of mild to moderate deformities. The Kalish-Austin bunionectomy is a modification of the Austin bunionectomy. It also is a V-shaped bone cut but is typically used for greater degrees of bunion deformities.

Fitting Preschool Children's Shoes

We discussed fitting infants' shoes in the last article, now your child is past the infant stage and into preschool. Children have usually developed their natural gait by this time, and are running and making lateral movements. At this stage children would rather be running than walking. Being more active requires a different type of shoe and different fitting of the shoes. The growth pattern will change, depending on the child, from a steady growth about every three months, to a spurt pattern. The foot may not grow for a period of time and suddenly grow a size or more in a short period of time. Due to the fact every child is different it is impossible to predict this change in growth pattern. The parent should check, or have a shoe fitter check the child's shoes every two or three months.

Each of the muscles in the lower leg are contained in what is called a muscle compartment. Just like an orange or grapefruit, where the fruit is divided by fibrous sheaths into identifiable sections, the muscles of the lower leg are also divided by fibrous sheaths into identifiable muscle compartments. There are four muscle compartments in the lower leg: two in the back of the lower leg (i.e. posterior compartments), one on the front of the lower leg (i.e. anterior compartment) and one on the outside of the lower leg (i.e. lateral compartment). Each of the four muscle compartments contain at least two individual muscles, which are surrounded by the fibrous sheath which wraps around the muscles of the compartment.

Because of the arrangement of the muscles of the lower leg into four compartments, an individual can develop two types of compartment syndrome: acute and chronic. Acute compartment syndrome is caused by direct trauma to the lower leg, such as that occurs during a motor vehicle accident where possibly one of the leg bones is broken. Blood rushing into the muscle compartment has no way to escape, causing a relatively sudden rise in the pressure in the muscle compartment. The increased pressure inside the muscle compartment can become so high that it clamps down on the arteries and nerves going through the leg into the foot. The result may be a loss of pulse and blood supply to the foot, loss of nerve function to the foot, and severe pain. Acute compartment syndrome requires immediate surgical attention or the individual may develop permanent deformity and disability in the leg and foot.

Bone spurs of the toes most commonly occur on the fifth toe. They occur less frequently on the other toes. The areas of the fifth toe that can form bone spurs are the outside of the toe next to the toenail, the inside of the toe near the tip of the toe where the toe presses up against the fourth toe, and on the inside of the base of the fifth toe. When the spur is at the base of the fifth toe, it is often associated with a soft corn between the fourth and fifth toes (See surgical correction of soft corns). Bone spurs can also occur on the side of any toe. Bone spurs in the toes are associated with excessive pressure of the toes pressing on one another while wearing shoes.

Surgical Procedure

In thirty years of fitting children's shoes I have seen many changes in the shoe industry. This is especially true in the style of shoes that parents are purchasing for their babies. Hard leather soles and stiff uppers were the rule many years ago. Since that time we have progressed to rubber or PVC soles. Soft leather uppers that conform to the foot and offer greater freedom of movement are now recommended. Narrow, medium and wide widths have since replaced the traditional B,C,D,E,EE. With all the changes in the children's shoe industry one constant remains, no matter what style of shoes you choose for your baby, they need to fit properly.

Foot problems normally found in adults are now being found among children. I have observed this more in the last ten years. In most cases this can be attributed to ill fitting or improper footwear. Often parents don't know how a shoe should fit or what areas of the shoe need to be checked for proper fitting. Hopefully this article will help insure that parents are more aware of how to fit children's shoes.