Curly or Hammer Toes in Infants and Toddlers

Parents are often concerned about infants and toddlers having curly toes or toes that are already hammered. This is a very common chief complaint. They worry that their children will have pain and misshapen toes/deformities/hammertoes later in life. They want to do everything for these children (rightfully so). Common “reverse deformity stretching” aka stretching in the opposite direction of the deformity, is sometimes not enough and there can be deforming forces working against these daily stretches. These deforming forces are seen in kids with flexible flatfeet (which most kids have at this age). Surgery is highly discouraged for this condition.

 This child is an 11-month-old who presented as a new patient initially at 6 months with a “curly” lesser digit on one of his feet. At that initial evaluation parents were given stretching exercises for the toe to try and help straighten the deformity. Today he presents at 11 months and is starting to cruise (hold onto objects to walk). 

Bottom line: the patient was dispensed littlesteps foot orthotics today (for reasons below) and will do phenomenal.

Picture #1 – Curly Toe Deformity

This patient illustrates many pediatric ideas :

1 – Flexor stabilization of the lesser digits (by the FDL) is a powerful deforming force of the lesser digits. Kids with pre-existing digital deformities will worsen without intervention.

2 – Flexible flatfeet causes overuse/overfiring of the FDL. Whether it is severe or typical flexible flatfoot in these kids the stabilization forces are still seen.

3 – Littlesteps stabilize the heel valgus/eversion/flexible flatfoot and thus significantly decreases the instability of the child and thus decreases the unnecessary “firing” of the flexors/FDL,   allowing manual stretching to achieve better results by straightening toes that are more curly than desired.

This is a classic case of a patient with flexible flatfoot who, as they begin to walk, has significant “firing” and overuse of the flexor tendons of the feet for stabilization. This issue, in this patient’s case and with many digital deformities, is that the contracture will often not allow the “curling” of the toe to straighten out over time and in many cases will make the issue worse. The patient is an almost 1 year old who is now beginning to cruise. The patient’s father has noticed that when he gets up and holds onto something that he will almost be able to stand for a brief time, however he sees a significant amount of toe contracture of the lesser toes of both feet. The patient’s Dad especially sees the affected toe (3rd digit,) which is adductovarus and plantarflexed, flex even more to the point in which it curls under the foot. The patient will then  turn his ankle and fall. Dad is concerned about this ankle collapse as well as concerned that the toe stretching exercises he does with him nightly will not work as well. Dad is “reverse stretching” the toe when he can so that to give the toe as much opportunity to straighten. Dad is aware that the curly toe may not fully “uncurl” but wants to do everything possible to help it while the child is flexible.

Picture #2 – Flexible Flatfoot stance

The child is dispensed littlesteps to stabilize the rearfoot (calcaneal valgus) so that the stabilizing lesser toe tendons do not have to over fire and increase/preserve the curly toe. Standing on the littlesteps there is noticeably less flexion contraction and a total removal of ankle instability. Videos and pictures are taken.  littlesteps have a deep 30mm UCBL heel cup (to stabilize heel valgus) with a medial skive (to stabilize the sustentaculum tali/STH0, medial and lateral longitudinal arch support and a lateral flange to cut down on abduction of the foot . 

Picture #3 – Curly Toe with active flexor contracture/stabilization

For more information, find us:
FB @nolaro
Twitter @Nolaro24LLC
nolaro24.com
info@nolaro24.com

Case Study for Toe Walking

Idiopathic Toe Walking: A common Mis-diagnosis
which is actually secondary to flexible flatfoot

By Dr Louis DeCaro

This is the case of a 2 year old child. She is a late walker (20 months). The patient has been walking for 4 months, mostly still only cruising, with off and on Toe walking.
The child is struggling in early intervention with hip and core strength. She was sent to me to evaluate significant ankle collapse and toe walking. The patient was dispensed littleSTEPS and will do phenomenal.
This patient illustrates many pediatric ideas :
1. The ankle collapse is NOT from the ankle (seen in comparison to picture #1 barefoot and picture #3 in littleSTEPS). It is from the foot!
2. A major cause of toe walking is a flexible flatfoot (explained below)
3. Early intervention will struggle with GM goals until the foundation is secured! It is now – she will be off to the races!

This is a classic case of the patient having SUCH a flexible flatfoot that she must toe walk to compensate. That is basically the only way the child can balance and walk (by going up on her toes). Traditionally this is diagnosed as idiopathic toe walking. The child does not have a rigid flatfoot, it is flexible, or as I refer to it a “False flexible flatfoot” – meaning that the significant flexibility of the foot at this age causes increased pronation and the ankle collapses which occludes the arch. When the patient stands on their tippy toes the calcaneus inverts and an arch “pops out”. Mom is given a handout of an article I published on this. Due to the extreme nature of the flexible foot the ankle collapses, the hip muscles are not able to properly develop, and walking is delayed. The foundation of the child is inhibiting her from gross motor goals. She only needs to be supported at the foot, because that is where the issue is coming from. Supporting above the ankle inhibits movement and is unnecessary. With littleSTEPS orthotics she is seen standing in resting calcaneal stance position with a much better posture and decreased base of gait (more parallel stance). This will significantly allow the core and hip muscles to fire more normally and get stronger faster. The child may or may not need OTS following this core strengthening and flexible foot phase however it is too early to tell.

Picture #3

MAKE SURE YOUR PEDIATRIC PATIENTS ARE READY TO GO BACK TO SCHOOL!

With thoughts of school right around the corner, most parents go buy new shoes for their kids in August. It’s time for you to contact them and get them to check their kid’s orthotics to make sure they are still the right size as well. Chances are that they will need a new size for their new shoes! Get parents to bring kids in to be fitted for their new larger size, and have them bring their new shoes.

Here’s how to check if your patients need a new size:

We suggest that you do a mailing to the parents of all of your pediatric patients, and include our flyer on making sure kids have the correct fit for their orthotics, and include a link on your website to download it. We can customize it for you with your logo and office information.

You can find the flyer HERE

If you would like it personalized, please contact Casey Hoffman casey@nolaro24.com. Please include a .jpg of your company’s logo.

SPECIAL PROMO OFFER on pair pricing for 10 or more pairs GOING ON NOW – Call 877-792-4669 for more information! Promo offer valid from July 27-31, 2018

FB @nolaro
Twitter @Nolaro24LLC
nolaro24.com