Home » Pediatric Foot and Ankle Pain: Expert Guidance for Parents

Pediatric Foot and Ankle Pain: Expert Guidance for Parents

by Elaina

Common Causes of Foot Pain in Children

A sprain is a stretch and/or tear of a ligament, the tissue connecting two bones. Sprains can occur with trauma, such as a fall or with chronic overuse of an area. Signs of a sprain include pain, instability of the joint, and swelling or bruising. The R.I.C.E. formula can be used to treat mild sprains. Rest (the child should stay off the injured foot as much as possible), Ice (apply ice wrapped in a towel to the injured area for 20 minutes every 2-3 hours), Compression (an elastic wrap should be applied to the injured area, and the child should wear a brace to limit movement) and Elevation (the child’s foot should be raised so that it is above heart level). This will help decrease swelling and pain. A severe sprain may require an x-ray or immobilization of the foot by a cast. A strain is a stretch and/or tear of a muscle and/or tendon. A child who has a strain will have pain with movement and will often have localized swelling or a feeling of muscle spasm. Treatment is R.I.C.E. and sometimes rest in severe cases. Most frequently strains occur because of overuse or a sudden increase in activity. Walking up stairs two at a time, running, jumping or participating in sports are common activities that can cause a strain.

2.1. Sprains and Strains

  • Rest: decrease or stop activity and try to stay off the injured area.
  • Ice: Apply ice for 20 minutes every 3 or 4 hours. Do not apply ice directly to the skin. Use a gel pack or bag of frozen vegetables, and elevate the injured area on a pillow or above heart level to help prevent swelling. Compression with an elastic bandage may also aid in reducing swelling.
  • Compression
  • Elevation

Your child is doing a gymnastics dismount off the beam, a cheerleading jump, or maybe your preschooler was running and took a turn too quickly. All these scenarios can lead to a sprain or strain of the foot or ankle. A sprain is an injury to a ligament, which is the tissue that connects one bone to another and usually involves a stretching or tearing of the ligament. Ankle sprains are the most common type of sprain and are more frequent in sports that involve jumping and quick changes in direction. Signs of a sprain may include pain, inability to use the foot or move it normally, swelling, and bruising. A strain is an injury to a muscle and/or tendon, the tissue that connects muscles to bones, and is caused by twisting or pulling it too far. High impact, stress-related activity or force may lead to overuse of the muscles and contribute to a strain. Often with a minor strain, your child may still be able to bear weight or move the affected limb. Treatment for a sprain or strain is R.I.C.E.

Growth Plate Injuries

The growth plate is the area at the end of children’s bones that is responsible for the bone’s lengthening. It is weaker than the surrounding bone and tendon, making it more susceptible to chronic injuries from accumulation of micro trauma or a sudden serious injury. Growth plate injuries occur up to the age of 16 for girls and 14 for boys because girls stop growing approximately 2 years after they start their menstrual period, and boys stop growing when their growth plate at the end of the bone closes. The growth plate gradually changes into solid bone as a child gets older. This happens after the child has stopped growing and isn’t injured again in that area. An injury can cause the growth plate to either stop growing prematurely or to grow more than it should. Occasionally, a fractured piece of the bone will actually cover part of the growth plate and grow to be a part of the bone. This may also disturb the normal growth of the bone. If the growth plate has been injured, it can cause the bone to become crooked or not as long as it should be. This type of injury usually requires a lot of rest and in some cases, a severe overgrowth, surgery may be required to remove the extra bone. Any sudden severe pain should be evaluated by a podiatrist to rule out a growth plate injury from a bone fracture.

Overuse Injuries

Keep in mind that all of these conditions are self-limited when the aggravating activity is discontinued or reduced, and there is complete resolution when the injury has healed. Sometimes full recovery includes growth plate closure and potential asymmetry of a long bone. Overuse injuries should be managed by controlling the child’s activity to a pain-free level. Activity level is based on the amount of pain during and after the activity. If a child has pain during or after an activity, a decrease in activity is necessary. A child is able to participate in an activity that is pain-free, and light activity may begin once there is no pain with usual activity. Easing back into activity is important to prevent a further injury. If an abrupt return to an aggravating activity occurs, a reinjury is highly likely. This entire process can take several weeks to several months depending on the injury. A doctor or sports physical therapist can guide you with a specific timeline.

Overuse injuries are very common among children in sports. They can occur in virtually any area of the body where repetitive stress is applied and are caused by an intensity, duration, or frequency of activity that is beyond the body’s capacity to tolerate. These injuries come on gradually and can be hard to diagnose. Often the child will not recall a specific injury but will complain of pain and may have been performing an activity repeatedly for several days or weeks leading up to the injury. Overuse injuries to the growth plate cause pain and localized tenderness and may result in a decreased ability to comfortably participate in an activity that the child has previously enjoyed.

Common Causes of Ankle Pain in Children

A fracture is a break in the bone. Fractures in children can sometimes be difficult to diagnose because it is sometimes hard for a child to explain the severity of the pain or recall the incident that caused the injury. A child with a broken foot or ankle may have pain, swelling, and difficulty walking. If a child has significant pain and swelling or is unable to put weight on the foot or walk, he/she should be evaluated by a physician. Some fractures are obvious on x-ray and require casting. Other fractures, especially those through the growth plate, may be less obvious. An MRI or CT scan may be necessary to further evaluate these injuries. High-energy fractures or fractures that involve joints may need evaluation by a pediatric orthopedic surgeon and can sometimes require surgical intervention.

The most common source of foot or ankle pain in children is simple sprains and strains. A sprain is an injury to a ligament, the tissue that connects bones to each other. Sprained ankles are often caused by trauma, such as falling or being injured while playing. Children will often ‘twist’ the ankle and experience immediate pain and swelling. The swelling is due to blood and other fluids that accumulate as the body reacts to the injury. The best initial treatment for a sprain is RICE (rest, ice, compression, elevation). If the child is not able to put weight on the ankle, there may be a chance of a fracture and the child should be evaluated by a doctor. An ankle sprain can be a re-injury if not rehabilitated properly and can, on occasion, lead to chronic ankle instability.

Ankle Sprains

Treatment for a sprain involves PRICE (protection, rest, ice, compression, elevation) and in more severe cases using a brace and keeping weight off the ankle for a period of time. A severe sprain may require the ankle to be immobilized, casted, or in rare cases, may require surgical repair. It is important to seek treatment if your child is unable to put weight on the ankle or has severe pain and swelling, as untreated ankle sprains can cause prolonged pain, instability of the ankle, and weakness which can increase the risk of further ankle injuries.

The severity of the sprain is determined by the degree of pain, amount of swelling, bruising, and difficulty putting weight on the ankle. Sprains are graded on a scale of 1-3. Grade 1 is mild damage and stretching of the ligament with a little pain and swelling, grade 2 is a partial tear of the ligament with moderate pain and swelling, and grade 3 is a complete tear of the ligament, which can cause severe pain and swelling as well as marked instability of the ankle. High-grade ankle sprains and those to the inside of the ankle are more likely to be associated with fractures.

Ankle sprains are the most common injury in children and are often the result of a fall or participating in sports. A sprain occurs when the ligaments that support the ankle are stretched or torn. It is most common for the ligaments on the outside of the ankle to be sprained. Sprains can range in severity from partial tears of the ligament to a complete tear or separation of the ligament from the bone.

Fractures

The word fracture implies a break in the bone and yet there are various forms of fracture, each with specific implications for treatment and healing. An incomplete fracture in children is one where the bone is still partially aligned and buckling rather than fully broken. This is a stable injury and generally heals well with a few weeks of casting. A torus or buckle fracture is a minimal impact injury and as such is most often caused by falling from standing height. This mechanism makes it a common injury in children. A torus fracture causes one side of the bone to bend upon itself and is stable. This injury too will heal well within a month when immobilized with a cast. A greenstick fracture is one where the bone bends and then breaks in a manner similar to snapping a fresh tree branch. This is an unstable injury but naturally heals in a stable position given the incomplete nature of the break. The most severe and unstable fractures in children are growth plate (Physis) fractures. This is where the bone fractures through the growth plate and so results in a disruption to the normal pattern of bone growth. This is the only form of pediatric bone fracture and as such special consideration for age and stage of development is given when choosing a mode of treatment. A Salter-Harris type 1 fracture is a separation of the growth plate from the bone and is generally managed conservatively with several weeks of casting, late x-ray and physiotherapy to restore normal strength and function in the area. Any other growth plate fractures are managed in consultation with an orthopedic surgeon.

A fracture (break) of a bone is a fairly common injury in childhood, with about 1 in 3 children having at least 1 significant fracture by 18 years of age. Most (but not all) fractures cause significant pain, so the child’s limp will be more severe than that caused by a sprain. Swelling and bruising may develop quickly, or in some cases not until a few days later, possibly spreading some distance away from the site of pain. The child is likely to be very tender directly over the site of the fracture. Depending on the severity and exact location of the fracture, your child may still be able to walk, may walk with a limp or be totally unable to weight bear on that limb. In very severe fractures (e.g. growth plate fractures or dislocations), the deformity may be obvious and an abnormal “crunching” sensation may be felt or heard coming from the joint.

When to Seek Medical Attention

For foot or ankle pain that is severe or has been persistent for over a week, it is a good idea to be evaluated by a physician. If your child sustains an injury and is unable to walk or put weight on the affected foot, this is a definite indication that they should be examined by a doctor. If there is swelling that does not improve with 24 hours of R.I.C.E. treatment, do not hesitate to make an appointment with a medical professional. A concerning symptom would be if the pain is waking the child from sleep. This could be an indication of a serious problem and should be addressed when possible with a physician. If there are any systemic symptoms associated with the foot or ankle pain, that may be a sign of a more complicated problem. Systemic symptoms include but are not limited to: fevers, malaise, weakness, weight loss or loss of appetite. Pain that the child and/or parent are concerned about should be taken seriously. If you feel that “something is not right” with the pain that your child is experiencing, it is reasonable to seek medical attention from a qualified health professional. Remember the lower extremity exists for mobility and sensation. Any loss of, or abnormal, sensation or difficulty with mobility can be an indication of a serious problem and should be evaluated without delay. Because some foot and ankle conditions can have long term consequences, it is important to be evaluated and properly diagnosed in a timely manner.

Red Flags for Foot Pain

If a child has sustained an acute injury and there is an inability to bear weight, it is most likely that a fractured bone is the cause. This is especially true if there is a specific event that the child can recall leading to the onset of pain. Injuries in children such as ligament sprains and muscle strains are uncommon and should be treated with the same urgency that one would address a similar adult injury. Many “sprains” and “strains” in a child are occult growth plate fractures which carry potential long-term complications if not treated appropriately. An injury with pain located at the juncture of a bone and a joint, or changes in joint shape with or without pain, are also situations where the injury may be more than just a soft tissue sprain. These cases should be further evaluated by a healthcare provider to determine if there is a potential growth plate injury in the affected joint. A growth plate injury will require more caution in treatment to avoid potential damage and complications. RICE therapy for acute injury with some initial activity avoidance and a subsequent slow return to activities is a safe common formula that can be employed by parents. However, if there is doubt of a potential broken bone or growth plate injury, it is best to come to specific activity restrictions from a plain film x-ray and consultation with a pediatric orthopedist.

The most important factor in discerning benign foot pain from a potentially serious condition is to evaluate a child’s ability to bear weight. If a child is not able to walk, this is an urgent situation and a physician should be contacted immediately. It is never normal for a child to limp. If a child is limping, then pain is significant despite the severity. Any refusal to bear weight on the injured foot with or without pain is a sign of a more significant injury. Some children will alter their gait to avoid pain by walking on their toes, or by using one foot as a kickstand. Observation of gait changes is sometimes difficult because it is not uncommon for children to mimic the act of limping in an attempt to be excused from their normal activities.

Red Flags for Ankle Pain

A lot of swelling can be seen in the immediate period following an injury, and this is a normal response of the body to the damage. The swelling is caused by bleeding from the injury into the joint and fluid escaping from the blood vessels into the tissues surrounding the injury. This excess fluid in and around the joint causes compression of the joint and pain when trying to move the joint in any direction. If a lot of swelling occurs, it is a sign that there has been a major injury to the joint, and it is therefore crucial that you consult your family GP or physiotherapist. Timing is crucial with swelling; if swelling persists for more than 3-4 days post-injury, it is vital that a medical professional examines the injury. This is because if swelling has been present in the joint for a number of days, the additional fluid in and around the joint will have caused excessive stiffness and weakness in the muscles and will prevent the normal dynamic stability of the ankle joint in everyday activities and, in turn, cause further damage to the joint.

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