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

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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

SMOs vs. Orthotics!

When to Brace OVER and When to Brace UNDER the Ankle

By Dr. Louis J DeCaro, DPM

My patient comes in with SMOs. The patient has “apparent” ankle collapse as well as significant ligamentous laxity of the ankle. However, on examination today it is seen that the “ankle collapse” is heavily dependent on the foot needing to pronate from its neutral position, not the ankle collapsing itself.  The heel eversion, forefoot abduction, combined with Sub talar joint collapse and significant forefoot varus all contribute to seemingly “dragging down the ankle”. To illustrate this to the parent the patient is seen standing in both RCSP (relaxed stance) and then sub talar neutral (the natural structural position of the foot relative to the leg-holding the patient in by inverting the foot to mimic what a UCBL would do) stance. In STN stance it is seen that the ankle is much more erect illustrating the imperativeness of good FOOT control, not necessarily ankle control. Standing in the littleSTEPS orthotic (which offers 30mm depth heel cup for calcaneus and rear foot control, along with lateral clips ((decreasing abduction)) and medial skiff ((holding up the sustentaculum tali))) from my fitting kit reveals that the FOOT is actually controlling the collapse of the ankle, not the ankle collapsing itself. Often SMOs are uncomfortable or “rub” medially around the ankle due to lack of foot control. Focus is often placed on “trapping down” the ankle and ignoring what is actually controlling the ankle drop – the foot position. Many times multiple adjustments” and padding are tried to counter this but without foot control the device remains uncomfortable.  Sometimes (in this case) adequate foot control can actually allow the patient to not have to wear a device over the ankle. This allows much more freedom for the patient in gait as well as many more options for shoe fit and ease of wear.  Going forward littleSTEPS deep UCBL orthotic devices will be provided, which places the foot in a position of maximum efficiency for ambulation with the subtalar joint in neutral position and the mid-tarsal joint locked.  

Before and After child standing on littleSTEPS

Functional littleSTEPS UCBL orthotic devices help compensate for the underlying biomechanical abnormalities which lead to the structural deformities and their resulting symptoms.  To the parent, I explained how deep functional custom UCBL’s will help control the biomechanical abnormalities and reduce the progression of the multiple foot problems which could occur in the future and also continuation and furthering of all other involved upper extremity issues and systems. A more normal gait and ankle motion will allow upper kinetic chain muscles to fire more readily and symmetrically. Orthoses also can help prevent the potential need for surgical intervention possibly needed in the future by preventing unnecessary chronic foot collapse that can lead to a rigid flatfoot deformity.

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