*Article Contains Surgical Photos*
Pediatric foot pain in the arch is very common. Many children that have lower arches can suffer from fatigue to the arch or pressure to bones in the foot. The most common bone in the foot that will cause pain in children from pressure is called the navicular. In about 15% of the population this bone is enlarged, and may even contain an extra bone called an os tibiale externum or accessory navicular.
The location of the navicular and accessory bone are marked with a pen in image
The combination of a lower arch and this extra bone can lead to worsening pain especially during cleated sports or dance which does not adequately support the foot.
Once pain has begun from this condition conservative therapy is not always successful. Treatment typically includes padding to painful bone, inserts or even custom arch supports that include a small cushion or pocket in the arch of device that reduces pressure at the painful location. Arch supports also reduce stress on the tibialis posterior tendon which attaches to the enlarged bone and is responsible for supporting arch. Stretching and strengthening of muscle can also help condition.
In the case condition fails to improve, surgical repair if required. This is called a Kidner Procedure.
The Kidner procedure is designed to remove the prominent bone, as well as tighten the tibialis posterior tendon that attaches at this location, therefore, recreating the arch. This surgery requires only a small incision and takes less than an hour to complete.
1) Enlarged bone is identified and marked
2) A small incision is made and tendon is martially removed from its attachment to enlarged navicular. Navicular bone is removed as well as any accessory navicular bone if present.
Tendon is gently freed from enlarged bone and protected to allow for removal of bone.
Os tibiale externum (accessory navicular) if removed, seen above. Enlarged navicular bone is also removed.
Before and after images of middle of arch demonstrating removal of extra bone, and enlarge navicular bone.
3) Posterior tibial tendon is reattached with an absorbable anchor inserted into the bone. The strong permanent sutures attached to this anchor are tied into the tendon, reattaching the released portion of tendon, but at the same time tightening the tendon to help strengthen the arch. Additional procedures are sometimes required in severe cases of pediatric flatfoot.
Bone has been removed and anchor with suture is attached, this will tighten posterior tibial tendon when tied.
4) Incision is closed with sutures that will be removed in two weeks. Patient in placed in a below the knee cast for 4 weeks. Patient then transitions into a walking boot for several weeks followed by several weeks in a brace. At 8 weeks patient returns to full activity, utilizing brace during sports for first month or more of activity.
The Kidner procedure is a minor surgery that can give children their pain free lives back, especially in sport. The procedure is brief and the vast majority of patients report very little pain during the immediate post-operative recovery period. If your child suffers from arch pain, don't hesitate to get them treated. No child should suffer pain from this treatable condition, let the doctors at FAANT help get your child back to being a kid.