~ Podiatric, Sports, and Dance Medicine ~
11-year-old with foot pain
A bright, beautiful, and spirited 11 year-old came in with her mom today. She was referred by a well-known sports medicine doctor here in NYC. The doctor wanted me to check whether or not this young lady should have orthotics. Her problem? Any time she tried to run with her friends, play sports, even walk in Disneyland or do anything you'd expect a healthy 11 year-old to do, she'd have foot pain. She could get pain atop the middles of her feet in the insteps. Or she could get pain on the outsides of her feet. Or she could get pain in her heels. She'd had blood tests, lots of X-rays, MRI, consults with orthopedists, pediatricians, and physical therapists. No one could find anything wrong.
She'd had orthotics, which didn't help. She'd been shown stretching exercises for her calves, which made things feel worse. She tried all different kinds of sports. All hurt except swimming and riding her bike.
I started my exam, after our history, the usual way. Looking at and poking, prodding, twisting, and feeling the texture of areas she said hurt. I was very meticulous and fortunately found little if anything that hurt except a tiny bit of right heel pain. Negative blood tests, negative X-rays, negative MRI, feet not flat, knee alignment normal, shoes in good shape and appropriate, not wearing orthotics or other potential gremlins. Why couldn't this otherwise perfectly-normal girl run around and have fun with her friends?
I watched her walk. Her heels lagged on the ground very late into each stride. When she walked she placed little to no weight on the balls of her feet at the end of each stride. It didn't look like she was using her calves. I checked her reflexes, which were normal. I checked the strength of the muscles in her legs which use the same spinal nerves as her calves. They were almost abnormally strong. Then I checked her calves. They were super loose. For nearly 30 years, super loose (or "overstretched" by the way I test calf stretch) has equated for me with weak. She didn't need orthotics (there is one contingency I will mention shortly), she needed calf strengthening. I showed her the quickest way to strengthen her calves, asked her to do that for a month, and then very gradually begin to add to her activities and call me anytime, but particularly after one month.
I asked a few more questions. I wasn't satisfied with the origin of her problem. How did her calves become weak to begin with three years ago? After some inquiring, I found out that she'd been wearing stiff-soled platform type white shoe/boots for about 6 months almost exclusively, just before the problems started. How did they remember? Because since then, all she's worn has been sneakers, because that's what all the health personnel told her to wear. The platforms were the last shoes she'd worn since the problem began. The stiff-soled platforms kept her from using her calves as they didn't bend at the toe. The pieces were all falling into place.
As far as orthotics (arch supports) are concerned, I discussed the following with her mom. There is a possibility that her arches will begin to hurt after she regains her calf strength. The strengthening program is designed to off-load her heels at the appropriate time in gait, to make them feel better and stop her from compensating her weight to these various places that hurt on and off. In off-loading her heels, she'll begin loading her arches and balls of her feet and toes, as any normal kid should do. Her arches may begin to bother her, as she hasn't been used to putting her weight forward with her calves for apparently at least three years. I said I wouldn't want them to lose faith in my treatment plan if this started to happen.
So her mom said, "Shouldn't we make orthotics for her now, just in case?" I thought about it and said, "Well, first off, kids are made out of rubber, and any discomfort they incur usually recovers quickly, as has been the case for your daughter for the past three years. Her toes should get stronger automatically as she carries forth with this program of calf-strengthening. Her new found toe strength should protect her arches. As she's had the problem for so long, I think it would be unwise to cast her for orthotics now, because she should have gained a large part of the required strength by the time the orthotics come in from the lab. If she picks up the orthotics around the same time the muscle strength kicks in, she may think she needs orthotics, when actually it very well may be the regained strength which keeps her asymptomatic. No, wait till the month goes by. If there are any problems as we proceed which actually need orthotics, we'll change our tune."
Her mom called me a month after our visit. All her daughter's pains had gone, though she did have a little arch pain at first, which went away in 10 days as she continued her exercise program. They regularly visit a kid's gymnastics center now and her daughter has begun gymnastics lessons. They'll keep me posted.
Thomas M. Novella, D.P.M.