09/27/2016    Keith L. Gurnick, DPM

7 Year Old with Crossover Toes

A 7 year old with crossover toes (could also be
called under-riding, or varus rotated toes)
will not improve or resolve on its own without
treatment. This condition is most likely
congenital, present at birth and was either
undetected, under-appreciated or if the
parent(s) had asked their pediatrician they
were told a) don't worry about it or b) it
will resolve on its own once the child begins
walking or c) wait until the child is older and
see if it gets better or d) if it doesn't hurt
leave it alone.

All of these answers are not only wrong, but
show a total lack of concern for the patient
for the future or an understanding of how the
foot should develop properly to function
properly over a lifetime.

I am deeply saddened to see a podiatrist opines
to leave it alone because it is not a problem
at this time. He too seems to show a total lack
of concern for this patient for the future or
an understanding of how the foot should develop
properly to function properly over a lifetime.

Even at the age of 7, there are many options
both conservative and surgical for this
patient, and to properly address the situation
and treat the patient, all options should be
weighed and discussed with the interested
parent(s) and the child. Treatment could
include "no treatment", but even at the age of
seven, daily toe stretching, daily toe taping
can be tried as a non-surgical attempt to see
how much of the flexible deformity can reduce.

This likely will be unsuccessful, however, even
after surgery, taping daily toe taping should
be included for 6 months to 1 year to help
insure the correction lasts. The involved toes
can be straightened with surgery on this
patient, and the surgery would be what we used
to call a flexor set at the level of the
deformity. This would be a flexor tenotomy, or
a tendon lengthening, and a capsular release at
either the distal or proximal inter-phalangeal
joint, depending on the level of the deformity
and which toe you need to do. This is a quick
outpatient procedure, with a quick recovery.
No bone work should be required at this time.

Proper foot function requires proper alignment
of the foot bones and joints for the ligaments
and muscles and tendons to also work properly.
This includes the rearfoot, midfoot, and
forefoot and toes.

Flexible rotated toes in the pediatric patient
will rarely if ever improve or resolve by
themselves over time and most will get worse
with time as the patient matures, becomes more
active and wears shoes that will place uneven
pressure on the already crowded toes. Much
the same way that a pediatric dentist would not
be dismissive of a pediatric malocclusion
condition, the pediatric podiatrist owes it to
the patient and the parents to educate
regarding the pros and cons of non-treatment,
the likely success and outcomes of conservative
vs. surgical treatment including disability,
recovery time and possible complications.

Given the right attention and information, most
caring and responsible parents will elect to
have treatment as opposed to "doing nothing"
for their child. I have had excellent success
with surgical correction on my pediatric
patients with this condition, which can cure
this problem and then save them a lifetime of
toe anguish (blisters, hammertoes, corns) and
shoe fitting problems.

Keith L. Gurnick, DPM, Los Angeles, CA

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