What Parents Should Know About Their Children's Feet

A Guide to Preventing Foot Problems as an Adult

Leonard R. Janis, D.P.M.

Foreword
Parents often ask if their child's foot problem could have been corrected sooner. Frequently, the answer is a resounding "yes." It is important to try to prevent foot problems before they occur. Most adult foot conditions actually begin in early childhood and progress as the child grows. Parents generally do not notice problems with their child's feet, so conditions that could have been prevented or corrected early never are properly evaluated or treated. When one finally does notice a foot condition, it can be too late to treat conservatively.

My experience, in more than 25 years of treating foot, ankle, and leg conditions, is that a great many of children's foot and leg problems are neglected. Some are obvious such as, a club foot, a child who has a severe intoeing gait, or infected ingrown toenails or warts. The parent notices these immediately and seeks out a competent member of the medical community for appropriate treatment. However, most other conditions which the parents think will go away or is reassured that the child will outgrow the problem, unfortunately continue into adulthood. Although some of the conditions will improve with time, most do not. The child, then, doesn't get any treatment. It is no wonder that 70% of all adults report some type of foot problem.

A complete history and physical examination will determine whether there is a problem, why the problem exists, ways to treat it, and any benefits or risks. What Parent's Should Know About Their Children's Feet provides information parents need to know to make informed choices regarding their children's foot health. Having this information will lead to a better understanding of common foot and leg conditions and their appropriate treatments from birth to adulthood.

Table of Contents Page (click on topic below)

Growth, Anatomy & Development
Growth and Development
Anatomy & Development
When to Examine for Problems
Foot & Leg Functions

Common Conditions Found at Birth
Congenital Dislocation of the Hip
Club Foot
Reverse Club Foot (Calcaneal Valgus)
Rocker Bottom Foot
Metatarsus Adductus (Turned in Foot)
Overlapping Toes
Webbed Toes (Syndactaly)
Extra Toes (Polydactaly)
Long Toes or Short Toes

Common Leg Conditions During Early Childhood
Intoeing (Pigeon-toed)/Out-toeing (Duck or Slue-footed)
Bowlegs/Knock Knees
Hyper-Extension of the Knees
Leg Length Differences
Tight Heel Cord (Equinus)
Night Cramps
Low Arched Feet (Flat Footed)
High Arched Feet

Conservative Treatment Methods
Shoes & Shoe Therapy
Orthotics (Custom Designed Insoles)

Common Childhood Nail & Skin Problems
Nails
Warts
Foreign Bodies
Fungus Infections
Contact Dermatitis
Impetigo
Eczema
Psoriasis
Foot Odor
Corns & Calluses

Conditions Affecting the Growth Centers of Bone
Hip Joint (Legg-Calvé-Perthes' Disease)
Knee Joint (Osgood-Schlatter's Disease)
Arch of Foot (Kohler's Disease)
Bone in Ball of Foot (Freiberg's Disease)
Heel (Sever's Disease)

Injury-related Conditions of the Foot & Leg
Fractures & Dislocations
Overuse Injuries of the Knee (Chondromalacia)
Shin Splints
Achilles Tendonitis

Common Hereditary & Developmental Bone Problems
Juvenile Bunions
Hammertoes/Mallet Toes
Medial Pinch Callus of the Great Toe
Tailor's Bunion
Accessory Bones (Extra Bones)
Ganglions & Cysts
Enlargement on the Back of the Heel (Haglund's Spur)

Childhood Ankle Conditions
Children in Dance & Sports
A Word About Children & Surgery
Conclusion

Growth, Anatomy & Development

Figure 1. Learning to Walk

Growth and Development
The average newborn weighs 7 to 7 ½ pounds at birth and is approximately 20 inches long. Growth is fairly rapid until age two, and then starts to slow until puberty. The growth rate in boys and girls is fairly equal until puberty, then the rate accelerates. Girls usually develop two years ahead of boys. After puberty, at approximately age 16 in girls and age 18 in boys, growth ceases. Typical "growing pains" are associated with the normal growth of the child due to differences in growth rate, and pressure of different structures as they grow.

At birth, a child's legs are relatively short when compared to the overall length of the body. From six months of age until puberty, the legs grow more rapidly, until the growth plates start to close.

Statistically, most people have one leg longer than the other. The right leg is slightly longer than the left 70%-75% of the time. The left foot is slightly longer than the right, although the right foot is somewhat broader.

Figure 2. Growth Patterns: Male vs. Female

The foot doubles in length from birth to age four. It increases in size almost one centimeter per year. At age 10, girls reach 90% of their foot growth, boys reach approximately 80%. By age 14, most girl's feet have stopped growing, whereas growth stops about 16 years of age in boys.

When an infant is born, its legs are rotated outward. In fact, there is twice as much rotation outward as there is inward. The femur, or thigh bone, and the tibia, the lower leg bone, untwist as growth occurs. Therefore, it is most important to know and to understand what is considered not normal. Conditions such as bowlegs, knock-knees, and walking up on the toes are acceptable, depending on what their developmental status is.

The same holds true with flat feet. A flattened foot structure where there is no arch is not abnormal in the first two years of life. We will discuss these conditions later in greater detail. Again we need to know what the normal foot structure is in order to make appropriate decisions as to when the child will either outgrow the condition or needs treatment.

Anatomy and Development
At birth there are relatively few bones in the foot. As the child matures, new areas of bone growth appear until the foot stops growing. By examination and taking an x-ray picture of the foot we can determine the physiological growth (maturity) as compared to the chronological growth (age) of the patient. Knowing this information helps determine whether treatment is necessary.

There are two very important "laws of nature", that determine the final outcome of how normal our feet will be later in life. The first applies to how bones grow, the other to soft tissues, such as muscles, tendons, and ligaments. Basically, the size and shape of any structure, be it bone or soft tissue, is determined by the amount and direction of pressure applied to it. If the structure is allowed to grow normally it will do so. If abnormal pressure is applied as growth occurs, such as a poorly fitting shoe, the structures will change and grow abnormally.

Hereditary factors can and do play an important role in how we develop. If a child's grandparents, father, and mother have flat feet, it would be highly likely that the child will also have flat feet. This may be normal because it is a hereditary condition, and the parents should not be overly concerned. However, not all conditions can be blamed on hereditary factors. In addition, even if there is a strong hereditary background, it does not mean that the condition should be neglected or left untreated.

When to Examine for Problems
Every newborn should be examined carefully for any potential foot or leg problem. These are usually easily diagnosed and are associated with congenital abnormalities such as clubfoot, overlapping toes, syndactaly (web toes), polydactaly (extra toes), or congenital dislocated hip. This is done by the physician in the newborn nursery where any limitation of motion or obvious problem can be evaluated and quickly treated.

Another examination of the feet and legs should be done at four to six months of age. This is the age at which most children try to stand and then begin to walk. A child can usually walk unassisted by 10-14 months. Most conditions associated with flat feet, bowlegs, knock knees, leg length differences, and ankle problems become obvious with standing. Hopefully, parents will follow the examination recommendations very carefully. This will help identify and allow treatment of most conditions without letting them get too advanced. An annual checkup or an examination at least every two years after age 10 is essential for proper foot care and prevention of problems.

Foot and Leg Functions
Basically our feet and legs function to do three things: provide support for the rest of the body, absorb shock, and adapt to the surface which we stand on.

The lower extremities are divided into three segments: the foot, ankle, and leg. It is the foot and it's many bones, ligaments, and tendon structures that acts as the foundation of support. The foot is uniquely designed to absorb shock and adapt to allow for proper function. Studies have determined that this marvelous structure works by changing the angles of how it strikes the ground and how each of its individual bones line up and when. The heel should be straight up and down and the bones in the ball of the foot should hit at the same time when the foot his he ground. If for example, this alignment is off, the foot, ankle, and leg will get out of alignment and not function properly. Structural changes then occur that lead to foot and ankle problems and to potential deformities.

The ankle and foot work together as a unit. The foot allows for motion to occur mostly side to side, whereas the ankle allows for the motion to occur up and down. Both of these motions are converted into rotation or twisting motions that is taken up into the leg. All three of these structures, the foot, ankle, and leg, must work together to insure proper function.

Common Conditions Found at Birth

Congenital Dislocation of the Hip
Definition: Congenital dislocation of the hip (CDH) is a condition where the head of the femur (thigh bone) is dislocated out of the hip joint.

Congenital dislocated hip is caused by abnormal position in the uterus or a problem with development. It is eight times more common in girls than boys, with the left hip being six to eight times more involved than the right. There is a strong family predisposition, usually running 20%-30%. The condition is characterized by looseness or laxity of the joint with one leg being shorter compared to the opposite leg. A "clunking" noise may be heard when pulling on the leg and then letting go, as it snaps back. It is easily diagnosed by examination and x-rays.

Treatment: Treatment is successful when initiated early. Typically, either double diapering, splints, or braces, can relocate the bone and it will heal uneventfully. Surgery is rarely needed.

Club Foot
Definition: Club foot is fairly common seen with a frequency of 1 per 1,500 births. It is a condition where the foot is held inward and upward in relation to the leg. Some club feet are fairly mild and flexible in nature while others are quite rigid and stiff.

Treatment: The treatment of choice is a series of foot casts done immediately after birth. This will manipulate the foot back into its normal position. Statistically, however, a club foot condition will require some type of surgery 70% of the time.

Reverse Club Foot (Calcaneal Valgus)
Definition: The reverse club foot deformity is seen at birth and is more frequently found than clubfoot. It occurs in 1 per 1,000 births. It is caused by improper intrauterine positioning and is easily recognized at birth. The entire foot is tilted upwards and can actually touch the front part of the lower leg. It is more commonly seen in girls and first-born children because of a tight fit in the mother's uterus.

Treatment: Unlike clubfoot, the treatment is relatively easy and the results excellent without surgery. The use of casts and braces are all that is needed.

Rocker Bottom Foot
Definition: A rocker bottom foot is a very rigid flat foot where there is absolutely no arch. In fact, as the name applies, the "arch" area of the foot looks like the rocker part of a rocking chair. It results when the keystone bone that supports the arch inside the foot becomes dislocated out of position. This is usually due to improper pressure inside the uterus.

Treatment: This type of foot problem is highly resistant to any type of casting, manipulation, or conservative care. Surgery is usually the treatment of choice.

Metatarsus Adductus (Turned in Foot)
Definition: The turning in of the front part of the foot (metatarsals) is one of the most frequently seen conditions in newborns. It is sometimes confused with or associated with being pigeon-toed, which is really a leg rotation problem. Metatarsus adductus frequently affects both feet, although only one foot may be involved. The outside border of the foot is characteristically "c" shaped, and the toes point inward.

Treatment: There are two types of metatarsus adductus: flexible and rigid. The flexible type can be easily straightened and treated with casts or special shoes. The rigid type is far more stubborn. If conservative care fails, surgery would be required.

Overlapping Toes
Definition: This condition is almost the rule rather than a real problem. That is, it is commonly seen in newborns. The most frequently involved toes are the second toe which overlaps the third. Equally as common is the inward rotation of the fifth toe overlapping the fourth. Overlapping is mentioned here only to note that it is very commonly seen and is not really a problem in most cases.

Treatment: Normally no treatment is needed as it is a condition that will be outgrown. Simple taping of one toe to another is usually all that is needed.

Webbed Toes (Syndactaly)
Definition: Webbed toes are another common and harmless condition. There is an absence of the web space between one or more of the toes. The web space may be either partially or completely filled in. This condition while not harmful, may cause some concern from a cosmetic point of view.

Treatment: No treatment is needed unless it is severe and involves all or most of the web spaces. Cosmetic surgery could then be performed if requested.

Extra Toes (Polydactaly)
Definition: Extra Toes are fairly uncommon and may involve one or both feet. Sometimes there are two big toes, other times an extra small or duplicate toe. While not a serious problem it usually affects the child's ability to wear shoes and certainly is a cosmetic problem.

Treatment: The treatment for an extra toe is surgical removal.

Long Toes or Short Toes
A common concern of parents regarding their children's feet is the length of the big toe compared to the second toe. The big toe may be longer or shorter than the second toe. When it is shorter it is called a Morton's foot and is characterized by a short first bone in the ball of the foot (metatarsal). The toe only appears to be shorter because it sits on a bone in the ball of the foot that is short. This type of foot tends to pronate or flatten and is associated with the formation of callouses.

When the great toe is longer than the second toe, the first bone in the ball of the foot is longer. This type of foot can form a skin callous directly beneath the first bone and contracted toes or hammertoes. Besides the great toe, the other toes may be affected. The cause is the same, a short metatarsal bone.

Treatment: It is of little concern whether the great toe is longer or shorter than the second toe. There is no treatment.

Common Leg Conditions During Early Childhood

Intoeing (Pigeon-toed) / Out-toeing (Duck or Slue footed)
Definition: When a baby is born there is normally two times as much outward rotation of the legs as compared to inward rotation. As the child grows this unequal rotation gradually begins to even itself out with the end result being an equal amount of inward and outward rotation. Pigeon-toed (inward) or slue-footed (outward) feet positions are fairly common in infants and toddlers with one leg usually affected more so than the other. However, both legs can be affected. The condition of intoeing or out-toeing results from involvement of a variety of soft tissue or bony structures or a combination of both. It may involve the hip, upper leg, knee joint, lower leg, ankle, or foot. A thorough examination is mandatory to determine the exact cause of the condition. Only then can it be decided whether the condition will be outgrown or needs treatment. The earlier it is diagnosed the better. It is unfortunate that parents are told their child will outgrow the problem, only to find out later that the condition still exists and would have responded well to treatment at a much younger age.

Treatment: Fortunately, well over 90% of intoeing/out-toeing conditions will self correct as the child grows. Mother Nature helps to rotate the legs around properly during three periods of the child's rapid growth: 1-3 years, 5-7 years, and during puberty. By age 10-12 only 4% of these types of problems still exist.

Treatment depends on the age of the patient. If detected early, simple changes in sitting or sleeping habits is all that is needed. The habit of sitting in a frog-legged style should be avoided. Sometimes a night splint may be used or even leg casts.

If the condition is left untreated until the child begins to walk it becomes more difficult to treat. The soft tissues shorten around the hip and the knee joints have already begun to tighten up in the wrong position. Simple non-painful braces worn during nap time or special supports that can be used during walking also can be used successfully. It is rare that more aggressive treatment is needed unless the child trips and falls frequently or has chronic pain.

Bowlegs/Knock Knees
Definition: At birth it is normal for the child to be bowlegged. The legs are not straight at this age. There is a normal progression of development of the legs. The legs are bowed from birth to age 2. They then become straight but become knock-kneed again from age 2 until age 4. From age 4 to about age 7 the process again reverses itself until they are basically straight. Often bowlegs/knock-knees are associated with flat feet. This will be discussed is a separate section. Bowleg conditions often look worse than they actually are. This is because the soft tissue structures of the calf area are rotated to the outside of the leg making it appear more bowed. As the child grows, this apparent bowleg appearance reduces and goes away.

There are some very rare conditions (rickets, Vitamin D deficiency, and bone growth abnormalities) that need to be ruled out in some cases. Both legs are usually affected. If only one leg is affected it may be due to some other problem such as laxity of the ligaments in the knee, a hip problem, or significant difference in the length of the legs.

Treatment: Most treatments associated with these conditions are actually directed at supporting the foot structure to keep the arch from falling. As previously described, since most of the time the problem self corrects, no treatment is needed. However, if needed, appropriate casts and/or braces can make a significant difference. Surgery is rarely indicated unless the child has a severe problem that has not corrected or greatly improved by conservative treatment.

Hyper-Extension of the Knees
Definition: Also known as genu-recurvatum, this condition looks like the knees are actually bent backwards. It is often seen with excessive laxity or hypermobility of the soft tissue structures (muscles, ligaments) that support the knee joint. When standing the pressure on the knees from the child's weight makes it more apparent.

Treatment: Fortunately this condition almost always self corrects as the child matures. The best treatment is to do exercises that strengthen the muscles around the knee joint or use braces that help stabilize the knee. If left untreated, the laxity can result in arthritic changes in the knee joint.

Leg Length Differences
Definition: Numerous studies have determined that almost 90% of the population has a difference in the length of their legs of up to ¼ of an inch. Therefore, it is not necessarily abnormal to have a leg length difference. However, measurements must be made to determine if a leg length difference is an influence on the total condition of the patient. For example, a child with a problem with their right knee or a low arch only on the right foot may have a faulty foot structure influenced by too long a leg on the right side. In an attempt to help equalize and straighten the body, the arch of the right foot may have lowered to compensate. Conversely, the arch of the left foot may attempt to lift up. An additional way for the body to compensate is for the foot on the long leg side to rotate more outwardly.

While 90% of the time one leg is longer than the other, 80% of the time the symptoms or problem will be located on the long leg side. This is because there is more pressure on the long leg side. Subsequently the foot and leg structure has to give more. Symptoms frequently seen on the long leg side are inside arch problems, inside knee pain and shin splints. Conversely, on the short leg side we often see symptoms of outside foot problems, problems on the outside portion of the knee, upper leg and lower back symptoms. These are generalizations, but they are true most of the time.

Differences in leg length are due to four variations in structure or combinations of all four: bone to bone length, how the bones are situated in the soft tissue (muscle tightness), combinations of both, or from the foot structure.

Treatment: Different types of doctors treat the problem in different ways. Some do not feel there is a real problem with one leg longer or shorter than the other unless the difference exceeds more than ½ an inch.

In my opinion, I look at the condition as only one part of the entire examination. Treatment depends on whether or not the difference in length is significant and how it may help as part of the overall treatment plan. In many instances, no treatment is needed. However, if treatment is warranted, just adding a lift to the short leg side is usually not enough. It is necessary to treat the entire foot and leg length as a unit. Therefore a lift on the short leg side is commonly incorporated into an arch support to support and cushion the foot while equalizing the leg length. Additionally, the leg length difference must be rechecked after treatment and at regular intervals, at least every 6 to 12 months. This is because with appropriate treatment the difference can actually change or even resolve. If the lift therapy is continued too long, it may adversely affect the foot or leg structure and cause continued pain.

Figure 25. Tight Heel Cord

Tight Heel Cord (Equinas)
Definition: The calf muscles by way of the Achilles tendon attach to the back of the heel bone. Besides helping to push the body forward when walking and running, they also act to hold the outside part of the foot firmly on the ground. If the Achilles tendon is too short, it puts tremendous and excessive pressure on the structure of the foot. In fact, a tight heel cord is a major contributing cause of childhood flat feet. That is, the tight heel cord forces the foot to break down and flatten. In rare instances, the foot doesn't break down and the child then literally has to walk up on their toes. The heel never really touches the ground.

Treatment: Stretching exercises are sometimes effective if the amount of tightness is not to severe. However, exercise must be done properly so as not to further affect the foot and continue to lower the arch. A lift inside the shoe can be used to bring the heel up to the proper height and take pressure off the tendon. Although rare, surgery can be used to lengthen the heel cord. This procedure, while highly successful, is usually done in combination with other procedures to correct any abnormal foot structure.

Figure 26. Night Cramps

Night Cramps
Definition: Often a child will wake up at night and complain of pain and cramping of the muscles in the legs, specifically the calf muscles. This generally occurs in children who are very active during the day. The cause of this is thought to be associated with a flatfoot structure and tight heel cord. These can cause an overuse of the muscles in the lower leg which results in a buildup of waste byproducts from muscular activity. During activity, the child's muscles contract and dispose of these byproducts. At rest the byproducts can buildup and are not eliminated from the muscles. The child then complains of pain in their legs.

Treatment: Massaging the legs helps to rid the tissues of the buildup of byproducts and helps relieves the pain. It is best to prevent the problem in the first place by providing a rest time before bedtime, as well as a soothing bath. In resistant cases, orthotics (custom-designed arch supports) or medication can be used. Regardless, the problem resolves as the child matures.

Low Arched Feet (Flat Footed)
Definition: There are three types of foot structures: normal, high arched, and low arched or flat feet. Flat feet are further divided into three types: the mild type in which the arch is still visible when the weight is on the foot, the moderate type in which, with weight on the foot, the arch is not visible, and the severe type in which, with weight on the foot, not only is the arch not visible but the area on the outside border of the foot looks "c" shaped.

Mild low arched feet are very common. It is estimated that 70% of the general population has a tendency toward excessive rolling in of the foot. This can lead to a formation of painful bunions, hammertoes, callouses, heel spurs, tendon injuries, and leg and back problems as an adult. Children rarely complain of pain, but often present with chronic leg fatigue, night cramps, appear clumsy, trip or fall, or have uneven shoe wear.

Most children never show an arch in their feet until they are 18-24 months old. This is because there is a normally occurring fat pad that occupies the arch and fills in the normal contour of the foot. An important difference in the flat foot of a child as compared to that of an adult is that much of the foot structure in the child is still cartilage which continues to develop until adulthood.

Much of this structure develops by age six. Therefore a low arched foot even up to this age is not necessarily abnormal. However, when walking begins between the ages of nine and eighteen months, pressure on the foot structure and its cartilage can adversely effect how the foot forms. Therefore, an examination of the foot very early and again just when the child begins to walk will help determine if any problems exist and whether treatment is advisable.

Most flat feet are flexible or non-rigid. While standing, if the foot flattens in the arch area and then without weight bearing looks normal it is the flexible flat foot type. Non-flexible or rigid flat feet show no arch with or without weight bearing. This type of foot usually is seen with a condition called tarsal coalition.

Tarsal coalition, a condition in which there is an abnormal connection between two bones of the foot. It can be either soft tissue, or a bony connection. Because of the flexibility of the cartilage and fibrous connections, this problem is rarely seen until the age of 10 to 13 years. At this age the soft cartilage in the foot changes and becomes bone. If a rigid connection forms it prevents the foot from moving properly. It is often associated with tightening of the muscles on the side of the leg. These muscles eventually go into spasm and the foot becomes locked into position (peroneal spastic flat foot). Fortunately this condition is rare and is seen in only one to two percent of children. It also seems to affects boys much more commonly than girls.

Treatment: There are 3 treatment options depending on the child's age and degree of problem: special shoe modifications, orthotics (custom designed arch supports), and surgery. Knowing what, or what not to do, and for how long, is critical to a successful treatment outcome. Since these treatments can be used for other conditions than flat foot, they will be discussed individually later.

Remember though, flat feet should be evaluated very early, beginning at seven to nine months of age or when the child begins to walk. Unfortunately, most people think little can be done to correct flat feet. This misconception is from a lack of understanding of the problem. Attention to proper treatment will encourage normal development.

Figure 32. High Arched Foot

High Arched Feet
The arch of the foot, if too high, does not absorb shock well nor does it adapt to the ground like a normal foot would do. Fortunately, the excessively high arched foot is infrequent. Because it can be associated with neuromuscular diseases, it is important to obtain a thorough family history with possible examination of other family members.
High-arched feet have basic characteristics associated with them, such as rigid hammertoes, painful and thick callouses, heel spurs, frequent ankle sprains, and a tight heel cord. The toes often contract upward. They can raise so high that it pulls the protected fat pad forward and away from the bottom of the ball of the foot. This results in considerable pain in the ball of the foot and arch.

High-arched feet do not respond well to conservative care. When an orthotic is used in treatment, it must be constructed with very soft and shock absorbing materials. Frequently, severely high-arched feet make it impossible to wear shoes or walk comfortably. Surgery, when indicated, is directed at correcting the many different toe, metatarsal, midfoot, heel, and tendon problems associated with high-arched feet. The surgery often needs to be staged, that is, divided into several different operations because of it's complexity. It is also common to fix only one foot at a time. The surgery to correct a high-arched foot repositions and realigns the bones and tendons of the foot structure therefore allowing for proper function.

Conservative Treatment Methods

Shoes and Shoe Therapy
Before we discuss "corrective" shoes, it is important to look at some of the standard recommendations for shoes by the shoe industry for each age group.

Infants generally should wear high top shoes with a soft, flexible bottom or sole. The only reason for a shoe at this age is for protection. Until 18 to 24 months of age, the high top shoe is used to merely hold the shoe on more securely. It does not truly support the ankle nor restrict motion of any kind. The soft, flexible sole allow the child's soft foot structures plenty of room to move and grow.

The oxford type "low top" shoe is best used as soon as the child begins to bear weight and then begins to walk. The low top allows for needed ankle motion. It not only affords protection for the foot, but more importantly provides a firm flat surface. The foot can function more correctly when on a flat surface. Therefore the shoe should also have a rigid shank. A rigid shank is where the sole of the shoe is reinforced from the heel to just in back of the bones in the ball of the foot. However, at the ball area, the shoe needs to be quite flexible. The correct size should be frequently checked as the child's foot grows rapidly.

Generally, a small raised heel helps prevent excessive wear and tear on the shoe. Leather is the preferred material. It is flexible, wears well, and most importantly, it breathes. Children's feet readily perspire. The leather allows moisture to pass through and evaporate easily. Natural cotton socks are excellent to help absorb perspiration.

Athletic types of shoes (tennis shoes) are fine to wear but are best reserved for times when the child is involved in very active or sporting type activities. Most parents have a tendency to allow the child to wear this type of shoe all of the time. While not considered the best choice for the foot structure, with today's construction methods, materials, and shoe industry technology, wearing this type of shoe is a close second choice and perfectly acceptable. The most important and best quality of athletic shoes is their ability to absorb shock. Be careful not to buy very cheap shoes. They cost less in general because they do not have the quality materials nor the proper construction needed to support the foot. They frequently do not last very long either. You always wind up buying shoes more frequently than really needed.

A word about other popular type of shoes: sandals made with a good arch support that do not cause irritation are fine during warmer weather; flip-flops other than for use at the pool are not recommended. Moccasins do not provide any support and only a minimal amount of protection. They should be avoided. Patent leather Mary Janes for the occasional dress up time are acceptable. However, they should not be worn for any extended period of time. The patent leather does not breathe and is frequently lined with a nylon type material. Children can develop friction burns on the skin of their feet from this type of shoe.

"Corrective Shoes" for various types of foot problems have been around for years and are widely recommended by all types of doctors. Surveys have indicated many pediatricians, podiatrists, and orthopedic doctors routinely prescribe "orthopedic" or corrective shoes. However, there is little evidence to justify using shoes to correct most foot problems. Shoes can be a valuable indicator of some type of foot problem when they wear abnormally or there is a noticeable gap between the foot and shoe.. But the problem with corrective shoes is that the foot moves within the shoe and could not possibly hold the foot in the desired position to really correct it.

Although shoes as a correction do exert some small measurable affect, most of the time the problem should not have been treated in the first place, or it corrected itself as the child grew. The shoe itself did very little.

Some shoe types and certain modifications are valuable to use in rare instances, and only for a short period of time. For instance, while it is best to cast an infant's foot when there is a problem, sometimes an open toed shoe can be used to realign a problem or help hold it in place.

Arch cookies, like corrective shoes, do little to alter a flat foot or other foot problem. Studies have determined the end result to be the same whether arch cookies were used or not.

Remember, shoes are a necessity to protect and support the foot structure and to help absorb shock. We walk an average of 70,000 miles in a lifetime. Good shoes will help ensure our feet will last a lifetime.

Orthotics (Custom Designed Insoles)
Orthotics are used for children to do three things: control and balance how the foot functions, to help correct a foot problem, and to aid in preventing a foot problem from getting worse. In an adult, an orthotic will not really correct anything that already exists or has occurred since birth. It acts more as an accommodation.

What is an orthotic? It is a custom designed foot support. It is not an arch support. Orthotics help to balance the front and back part of the foot structure to keep it in alignment with the ankle and leg. The arch is only secondarily affected. An arch support appears to help the arch because it pushes up on the soft tissues. When the support is removed the arch of the foot simply flattens back down. An orthotic balances the foot structure and allows for growth in a proper alignment. When growth has been completed, the orthotic can be discontinued, and the foot structure, now normal, will remain in the proper position.

Remember that initially, almost all children's feet pronate or appear to roll in. When they begin to walk, usually at age 10 to 15 months, their feet will look flat. If the doctor's examination determines an abnormal foot condition, treatment is best begun at that early age. Also recall that many foot problems can be influenced by intoeing and out-toeing. If these are present in addition to a foot condition, treatment is needed.

While there are literally hundreds of different styles of orthotics, there are really only two types: rigid and soft. Soft orthotics are generally reserved for adults who not only need control of their foot structure but cushioning as well. Children almost always require rigid orthotics. Do not confuse rigid or hard orthotics with discomfort. When made properly an orthotic is very comfor