Sever's Disease is much more common in boys than in girls. Most cases of Sever's Disease are found in children who are moderately obese. Sever's Disease can also occur in very active children. Sever's Disease is common in periods when activities for these children increase such as twice daily football practices in the fall or at the onset of track season. For additional information regarding symptoms and causes of Sever's Disease, please refer to the symptoms and biomechanics tabs on this page.

Treatment for Sever's Disease

Treatment of Sever's Disease depends upon the degree of symptoms experienced by the patient.

It is very important to treat any equinus deformity that the child may experience. Treating equinus neutralizes the load applied to the heel by the calf and Achilles tendon. For a detailed discussion on equinus, please refer to the biomechanics tab on this page.

Mild Symptoms - Wear a 3/8 heel lift at all times, not just during physical activity. It is important to use a firm lift and not a soft heel pad. Remember, we are trying to treat equinus. By raising the heel we weaken the pull of the mechanical load applied by the calf to the foot.

Calf stretches 6/day for 60 seconds each. Calf stretches are best accomplished by standing with the toes on the edge of a stretching block.

Moderate Symptoms - Follow the directions for minor symptoms and decrease activity including elimination of any athletic activity. In addition to stretching by day, a night stretching splint can be worn while sleeping.

Severe Symptoms - Follow the directions for mild and moderate symptoms. Children should be removed from sports activities such as football, basketball, soccer or gym class. A below knee walking cast with a heel lift or in severe cases, non-weight bearing fiberglass cast, may be indicated for 4-6 weeks. The cast should be applied in a mildly plantar flexed position. Cam Walkers should not be used for Sever's Disease unless they have a built in heel lift.

CMT is characterized by two types;

Type I

The characteristic finding of Type I CMT begin to develop in the late teens to early 20's. The most pronounced finding is the 'stork leg deformity' that occurs as the peroneal muscles of the lower leg begin to atrophy (become weak). Muscular wasting of the hands does occur but typically happens well after the onset of atrophy of the legs. Type I CMT progresses slowly over the patient's lifetime.

Neurological findings of Type I CMT include;

A decrease in the ability of the peripheral nerves of the hand and feet (a stocking glove distribution) to sense vibration, pain and temperature

Deep tendon reflexes are absent

EMG testing shows slow nerve conduction velocities with prolonged distal latencies.

Enlarged peripheral nerves that can be felt

Type II

Type II CMT shows many of the same neurological finding, only that they appear much later in life.

Treatment: Currently, there is no available method to slow or stop the progression of CMT therefore treatment is based upon symptoms. Many CMT patients require no treatment at all. Others find comfort in soft prescription orthotics or AFO braces that stabilize the leg.

Pediatric Flatfeet

Pediatric flatfoot is a problem seen often in a podiatrists office. Children usually don't have the verbal skills to express themselves with any degree of accuracy regarding medical problems. But children will give us indirect clues or indications of a problem. They'll ask to be carried or they'll want their legs and feet to be rubbed. And in the case of a symptomatic flatfoot, children will tend to express these complaints more so after they've been active. Pediatric flatfoot symptoms are due to the mechanical inefficiency of the flatfoot. Simply put, it just takes more work to walk with a flatfoot. Therefore, kids with flatfeet have to exert more effort during a day to keep up with the other kids.

Although most pediatric flatfeet are asymptomatic, there are several different types of pediatric flatfeet that cause pain and can be of significant concern. There are several congenital (from birth) deformities that we see that result in flatfeet. One of the more common congenital deformities is called a tarsal coalition. Tarsal refers to the bones of the rear portion of the foot and coalition refers to a bridge. What happens in cases of tarsal coalition is that a coalition or bridge of bone forms between two bones, limiting the range of motion of the joints of the foot. The end result is a rigid, painful flatfoot. This is a challenging condition to diagnosis in young children. The challenge lies in the fact that the radiographic findings of tarsal coalition don't become evident until the late teens. Part of the diagnostic challenge lies in the fact that the bridge of bone in young children is made of fibrous material and cannot be seen on x-ray. As the patient matures, the fibrous bridge begins to ossify (turn to bone). As this ossification progresses, the foot becomes markedly rigid and painful. MRI can be very helpful in the diagnosis of a tarsal coalition.

Adult Flatfeet

The inherited adult flatfoot can have many of the same problems that we've already discussed in children. The majority of adults with flatfeet simply complain of fatigue and an inability to get through the day comfortably. These are the same kids that we've just talked about, only they've grown up to become adults.

A second type of adult flat foot is an acquired flatfoot. An acquired flatfoot can be due to many different reason including trauma, arthritis and tendon rupture. Acquired flatfeet can be unilateral or bilateral and can be some of the more challenging flatfoot cases to manage. The most common symptomatic acquired flatfoot that I see is due to posterior tibial tendon dysfunction (PTTD). The posterior tibial tendon originates beneath the calf, descends along the inside of the ankle and inserts into the arch. Its' primary function is to support the height of the arch. When this tendon is damaged and becomes 'dysfunctional' the bones and joints of the arch begin to collapse. PTTD is more common in women and is seen with increasing frequency with increased age.

Treatment of Flatfeet

Treatment of pediatric and adult flatfeet depends upon each individual patient's symptoms. Pain should be the primary motivation for treatment. Treatment starts with a simple conservative approach in most cases.

Initial treatment of pediatric flatfeet starts with pediatric arch supports and shoe modifications. Arch supports can be OTC or prescription. Shoe modification can be performed by your pedorthist or shoe repair shop and include an arch cookie (glue in support) and reverse Thomas heel. A traditional Oxford shoe is the most common style of shoe that can accommodate these modifications. The key to initial treatment is to try the simple tricks and see how well they work. How do you know that they're working? You'll simply see a decrease in symptoms. The other consideration with kids is that they're going to grow out of things so quickly. I think it's money well spent to discuss your concerns with your podiatrist or pedorthist. They'll be able to recommend a treatment plan that may be significantly more cost effective for your child in the long run.

Initial treatment of the adult flatfoot is much the same as we've discussed with children. Try the easy things first such as an OTC rigid carbon graphite orthotic and eurocomfort shoes. You'd be amazed at what a decent pair of comfortable shoes can do to change a persons life. If the symptoms of a flatfoot don't respond to conservative care, consult your podiatrist. I would also like to stress that early treatment of some of the conditions that we've discussed, like PTTD, is very important. We've discussed the fact that PTTD is due to failure of the posterior tibial tendon. In the early stages of this condition, the tendon is inflamed and can be corrected. If the condition is allowed to progress, the tendon will eventually rupture leading to a surgical correction that can be quite extensive. Conservative care of adult flatfeet includes traditional Oxford shoes, arch supports, orthotics, OTC braces and Rx braces.

At first glance, flatfoot surgery would seem fairly simple with the primary surgical objective being to raise the arch. But in actuality it's much more complex than that. Much of the stability of the foot comes from the bones of the rearfoot. If a house has a bad basement, the rest of the house is in jeopardy. The same holds true for the foot. A faulty rearfoot jeopardizes the stability of the rest of the foot.

In addition to correcting the arch, we also need to consider how to restore the center of gravity over the foot. Quite often in flatfoot cases we see the arch collapse and the foot rolls in forcing the center of gravity to be carried somewhere out over the inside of the foot. That's a very important consideration when repairing flatfeet.

Flexible vs Rigid Flatfeet

When a patient is evaluated for flatfoot surgery, one of the first consideration made in surgical planning is whether the foot is flexible or rigid. Determining flexibility vs rigidity is a bit subjective. Your doctor will manipulate the foot to determine the degree of flexibility. This determination is important in defining the surgical treatment plan. Flexibility is assessed in all three cardinal planes; frontal, transverse and sagital. Flexible flatfeet can be treated with a number of procedures that are ambulatory with little post-operative disability. Rigid flatfeet, on the other hand, require a higher intensity of care with subsequently longer period of post-op care.

Surgical Treatment of Flexible Flatfeet

One common procedure used to treat flexible flatfeet involves placing a small metal implant in the subtalar joint to 'wedge' the foot and ankle into a more stable position. This procedure is referred to as a subtalar arthroeresis (STA-Peg procedure). Arthroeresis is not as invasive as other forms of surgical arch reconstruction, but may only be used in select cases of flexible flatfeet. Subtalar arthroeresis is often referred to as an internal cast, supplying support from within the subtalar joint. Sub talar arthroeresis is often performed with a procedure to lengthen the calf muscle and/or Achilles tendon. These procedures include an endoscopic gastrocnemius recession and/or Achilles tendon lengthening.

The following images show the steps used to perform a STA-Peg procedure. A STA-Peg procedure was one of the earliest methods of subtalar arthroeresis. Image 1 shows pre-operative planning marking the boundaries of the peroneal tendons and intermediate dorsal cutaneous nerve. In image 2 wee see the peroneal tendons retracted down and the intermediate dorsal cutaneous nerve retracted up. Image 3 show entry into the subtalar joint. Image 4 and 5 show preparation of the of the subtalar joint for the implant. And image 6 shows the implant in place. The capsule of the subtalar joint would be closed and skin reapposed with several non-absorbable sutures. patients can bear weight on the foot the same day. STA-Peg implants come in three sizes. Image 7 shows the implants and their corresponding insertion/sizing tools.

The second procedure that we'll describe to treat a flexible flatfoot is a modified Kidner procedure. The pictures below show the steps used to perform a modified Kidner procedure. A modified Kidner is often used in conjunction with other procedures to correct a flatfoot deformity. A modified Kidner procedure is also used in cases of a symptomatic os tibial externum (accessory bone of the medial arch as seen in the image to the left).

Image 1 shows the planned approach with the leg to the left and toes to the upper right. Image 2 shows deep tissue dissection and identification of the posterior tibial tendon sheath. Images 3-5 show dissection of the os tibiale externum from its' investment from within the posterior tibial tendon. Image 6 shows repair of the posterior tibial tendon with non-absorbable suture. Image 7 is final skin closure.

Image 8 shows the articular surface of a large os tibial externum. Os tibiale externum is found in 15% of the general population and functions in a way similar to your knee cap (patella), enabling its' associated muscle and tendon to function more effectively. The os tibiale externum articulates (forms a joint) with the navicular bone. Pain due to a symptomatic os tibial externum is often due to arthritis at this articulation. The forceps point to a focal area of degenerative change consistent with may be called osteochondritis dessicans. Osteochondritis dessicans describes erosion of cartilage that results in arthritic changes.

A modified Kidner procedure is performed on an out-patient basis using general anesthesia and a thigh tourniquet. The procedure takes approximately an hour to perform. Inherent in the term modified, a modified Kidner may include several additional steps not described in these pictures. Additional steps may include tendon transfer or tenodesis (anchoring the tendon to the bone). Post-op care may include a bandage, splint or cast. Some patients may ambulate following this surgery, others may not. The size of the os tibiale externum dictates whether a patient may walk post-op or not. The percentage of space taken up by the os tibiale externum within the tendon may be significant enough that immediate weight bearing would result in failure of the posterior tibial tendon. Your surgeon will be able to determine when you can return to ambulation during the procedure.

The long-term success or failure of a modified Kidner procedure can depend upon the treatment of the associated flatfoot. If the flattening of the foot is allowed to continue following a modified Kidner, continued stress will be placed upon the posterior tibial tendon. In some case, this will lead to failure of the PT tendon. Therefore, it is imperative to address the flatfoot at the time a modified Kidner is performed. A common procedure that would accompany a modified Kidner would be subtalar arthroeresis, medial column arthrodesis or lateral column lengthening.

Surgical Treatment of Rigid Flatfeet

Surgical treatment of the rigid flatfoot requires making structural changes to the bones and joints of the foot. The primary focus of these procedures is to realign the center of gravity of the body over the foot. These structural changes can be made in one or all three of the cardinal body planes as described above.

The majority of rigid flatfoot cases require an osteotomy of the heel to realign load bearing on the heel. Calcaneal osteotomies are used to correct frontal plane flatfoot deformities. An osteotomy of the heel is a surgical break through the body of the heel. This procedure is normally completed through a 3-4 cm incision on the lateral aspect of the heel. The heel bone is then shifted medially (towards the arch of the foot) and fixated with a screw or pin. This procedure carries many names including a calcaneal slide procedure or calcaneal off-set osteotomy. A calcaneal slide procedure needs to be performed in a hospital setting under general anesthesia. 6-8 weeks of non-weight bearing casting is required following this procedure.

Sagital plane flatfoot deformities are address with either an Achilles tendon lengthening or endoscopic gastrocnemius procedure. Clinical assessment of most adult flatfeet will show that equinus is present and needs to be addressed by either of these two procedures.

Medial column fusions are common in the treatment of a rigid flatfoot. Medial column fusions address frontal and sagital plane deformities. The location for the medial column fusion is determined on x-ray.  In a lateral x-ray of the foot, the lowest portion of the arch is identified. The low section of the arch will typically be the talo-navicular joint or the navicular cuneiform joint. One or more of these joints is fused in a medial column fusion. These procedures need to be completed in a hospital stetting under general anesthesia. A 6-8 week period of non-weight bearing casting is common.

Another method employed in treating flatfeet include a procedure called an Evans Procedure. An Evans Procedure is used to correct abduction of the forefoot. Abduction is a transverse plane deformity. The test used to determine the amount of abduction of the forefoot is called a 'too many toes sign'. In cases of extreme forefoot abduction, when the foot is viewed from the back, the 4th and 5th toes will be seen peeking out along the lateral aspect of the foot. The Evans procedure is used to wedge the foot back to a straight, or non-abducted position. An Evans procedure uses a bone graft to wedge the distal calcaneus, in effect lengthening the lateral column of the foot. An Evans procedure may be used in conjunction with any number of other flatfoot procedures.

Rigid flatfeet are also treated with a number of different tendon transfers. The most common tendon transfer used in flatfoot surgery is the transfer of the flexor hallucis longus tendon to the posterior tibial tendon. The posterior tibial tendon is the primary tendinous support of the medial arch. The posterior tibial tendon often fails in cases of flatfoot. Tendon transfers such as this serve to reinforce the PT tendon.

The treatment of a rigid flatfoot deformity can be challenging for both surgeon and patient. When planning rigid flatfoot correction, it's important that patients understand the degree of disability associated with the procedure. It is not unusual for many patients to bee off work for a period of 6 months or more when undergoing a rigid flatfoot repair.

How do we develop claw toes? Claw toes aren't due to ill fitting shoes or high heels. Claw toes develop  due to an imbalance in the tendons that move the toe. The two primary causes of claw toes are called extensor substitution and flexor substitution. These two conditions are explained in the biomechanics tab below.

Treatment Of Claw Toes

Treatment of hammer toes (including claw toes) ranges from simple shoe modifications to sophisticated surgical repair. Logic dictates that our initial attempts at treating hammer toes would include softer and wider shoes. Shoes such as clogs or Birkenstocks offer a wide toe box that in many instances may be enough of a change to allow pain free walking. Hammer toe pads are often used to control the motion of the toe to hold it or bind it in place so that it doesn't rub on the shoe. Many variations of pads are available for use. The right pad really depends upon the individual toe location and problem.

Surgical treatment of hammer toes varies from simple releases of the extensor tendon (top of the toe) to complex tendon transfers and bone fusions. The most commonly used hammer toe procedure is that which was described by Post in 1895 and is referred to today as the Post Arthroplasty or Post Procedure. The Post Procedure involves resecting (removing) the knuckle of the toe at the level of the proximal interphalangeal joint (PIPJ) This joint is the joint closest to the point where the toe attaches to the foot. Typically the Post Procedure will be performed in conjunction with a tendon release on the top (extensor surface) of the foot. The combination of these two procedures results in a toe that will lay flatter avoiding direct pressure from the shoe. The Post Procedure may be performed under local or general anesthesia.

The following pictures show the surgical steps of a claw toe procedure called a Post arthroplasty. Modifications of this procedure may include a fusion of the joint, pinning of the toe or digital implant. These photos show dissection at the level of the proximal interphalangeal joint (PIPJ) for correction of a hammer toe. Image 1 shows the pre-operative position of the hammer toe. Image 2 shows a release of the dorsal capsule and extensors tendons with a #15 blade at the level of the metatarsal phalangeal joint. Image 3 shows the long extensor tendon at the level of the PIPJ. In Image 4, the extensor tendon is reflected and the PIPJ ligaments released from the medial and lateral sides of the PIPJ. Image 5 show resection of the proximal phalangeal head with a pair of bone nippers. In Image 6 we see final closure of the wound.

Equinus is caused by soft tissue or bone pathology and caused by one or more of the following:

• Contracture or shortening of the Achilles tendon.
• Anterior ankle bone block.
• Posterior ankle contracture.
• Congential posterior ankle or tendo-Achilles contracture.

The presence of one or more of these conditions will limit the range of motion of the ankle resulting in equinus.

Folks with moderate to severe equinus will find a number of different foot problems as a result of a tight calf. These problems may include bunions, flat feet, hammer toes, tendonitis, heel pain and a host of other foot conditions. These problems evolve from our first steps as children and continue to develop through adulthood. Equinus contributes to the development of these problems by causing an imbalance between each of the muscle groups of the lower extremity.

Treatment of Equinus

The initial steps in treating equinus include the use of a heel lift and calf stretching exercises. Shoes with a higher heel are also helpful. Folks with equinus should also avoid going barefoot or in just their socks. Simply put, the lower the heel, the more problems you'll have with equinus related foot problems. 

In some cases, surgical care is required to lengthen the Achilles tendon. This procedure can also be performed endoscopically and is called an endoscopic gastrocnemius recession.  The following pictures show the steps used to perform an endoscopic gastrocnemius recession. Image 1&2 show the steps used to locate the incision site. The distance from the back of the heel to the front of the ankle is measured (between the red hash marks). This same distance is marked off on the back of the leg extending from the posterior heel proximally on the leg. This measurement will determine the approximate location of the gastrocnemius aponeurosis. The incision site is placed just distal to the terminus of the belly of the gastrocnemius muscle at the level of the aponeurosis. Image 3 shows a blunt obturator and slotted cannula. The obturator is placed inside the cannula and both instruments are used together to bluntly dissect across the posterior calf within the subcutaneous space, immediately superior to the gastrocnemius aponeurosis. Two incisions are use, one on the medial and another on the lateral aspect of the calf. The obturator and cannula are passed between these two incisions. Image 5 shows the introduction of a 4.0 mm endoscope into the slotted cannula. The slot in the cannula is place immediately adjacent to the gastrocnemius aponeurosis. Therefore, we use the cannula as a space to place the endoscope and the slot in the cannula to view the aponeurosis. Image 6 shows a view through the endoscope as a triangle knife is used to make the first pass through the gastrocnemius aponeurosis. Image 7 shows a completed release as evidenced by viewing the soleus muscle deep to the gastrocnemius aponeurosis. Image 8 shows the final skin closure.

An endoscopic gastrocnemius recession (EGR) is performed on an outpatient basis using a general anesthetic and thigh tourniquet. The procedure take approximately 15 minutes to complete. Patients are able to walk the same day of surgery. Follow-up care may include the use of compression hose to accommodate swelling and the use of an anticoagulant as a prophylactic measure to prevent deep vein thrombosis (DVT).

An alternative procedure to an EGR is a percutaneous Achilles tendon lengthening (TAL).  A percutaneous TAL is performed with three 0.5 cm stab incision and often does not require suture closure.  Each procedure has its advantages and disadvantages.  The EGR is an ambulatory procedure meaning that patients can walk on the leg the same day of surgery.  The disadvantage of the EGR is that it weakens the force of equinus by only 5-10%.  A TAL has a significantly greater impact on equinus in that it can weaken to force of equinus up to 50%.  The disadvantage of the TAL is that it is a non-ambulatory procedure and requires 6 weeks of non-weight bearing casting.

For more information regarding the biomechanical interaction of the leg, ankle and foot, be sure to view our pages on CT Band Syndrome.