Common, usually ordinary, and it settlesEmerging evidence
NHS inform says foot and ankle problems in children can come from an injury or from normal changes such as a growth spurt, expects the biggest change in the first couple of weeks and most problems to improve within 6 weeks, and says a child doesn't need to be pain-free to go to nursery or school. Paediatric Musculoskeletal Matters, a teaching resource for doctors, says foot pain in children is common, and that shoes that don't fit, ingrown toenails, blisters, splinters and verrucas are worth checking first.
There is no UK figure for how common it is. In 1,756 Finnish schoolchildren in their third and fifth school years, the ankle and foot were the commonest site of leg pain after the knee, and about 70% of those with leg pain said it limited them in some way.
Sources 1, 2, 3, 4
The causes by ageEmerging evidence
Babies and toddlers (under about 3): flat feet and walking on tiptoe are normal while children learn to walk. A toddler who suddenly won't walk or put weight on a leg needs checking the same day, because an injury or an infection is more likely at this age: bone infection was about 3 times as common under 3 in a Norwegian study, and young children don't always get a high temperature with it.
About 2 to 10: Köhler's disease (a limp and a sore inner midfoot, more often in boys), growing pains (usually from 3 to 12), flat feet that improve with age, and knocks and falls. About 8 to 15, especially active children in a growth spurt: Sever's disease at the back of the heel, Iselin's disease at the bump on the outer edge of the foot, a painful extra bone on the inner midfoot (our guides), and ankle sprains.
Teenagers: Freiberg's disease under the second or third toe, typically in girls; a stiff, painful flat foot or ankles that keep spraining (a tarsal coalition); stress fractures in young athletes, mostly in the shin rather than the foot; and ingrown toenails. At any age: juvenile arthritis, more often in girls, and, rarely, an infection or a tumour.
Sources 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19
Heel pain in an active child: usually Sever's diseaseStrong evidence
Sever's disease is the commonest cause of heel pain in active children: the Achilles tendon pulls on the growth area at the back of the heel bone. It hurts during and after running and jumping and at the end of the day, eases with rest, and the heel is tender when you gently squeeze its sides; it can make a child limp or walk on tiptoe. NHS inform says it can be painful but isn't serious and doesn't cause long-term damage.
Sources give slightly different ages: usually 8 to 14, with symptoms going when the growth plates close, around 12 to 14 (NHS inform), or 8 to 15 (NHS Lothian and the children's physiotherapists' leaflet). It is commoner in boys, during growth spurts, with tight calves, in high-impact sport and in children who specialise early in one sport. In Dutch general practice records from 2008 to 2010, it had been diagnosed in 3.7 of every 1,000 registered children aged 6 to 17, probably an underestimate, and both heels hurt in 61% of 85 children in one US clinic.
Sources 11, 12, 20, 21, 22
Flat feet and toe walking: usually normalStrong evidence
Most young children have flat feet. In 835 Austrian children aged 3 to 6, 44% had flexible flat feet (54% at 3 and 24% at 6), and under 1% had a flat foot that wasn't normal; a review of 34 studies agrees that a flat foot is normal at certain ages. Arches usually develop between 3 and 10, the NHS says, often becoming more noticeable between 6 and 10, NHS inform says; sources differ on the exact age. A flexible flat foot shows an arch when the child stands on tiptoe. A flat foot that stays flat on tiptoe, is stiff or painful, or is on one side only needs a GP, because it can be a tarsal coalition or an inflammatory arthritis.
Walking on tiptoe is common while toddlers learn to walk. In 1,436 Swedish children, 2.1% still walked on their toes at 5 and a half and 4.9% ever had; 79% of those who ever had stopped by 10 without treatment, and NHS inform says most children grow out of it between 2 and 7.
Sources 6, 23, 24, 5, 25, 2, 26, 27, 28
Growing pains: both legs, at night, gone by the morningMixed evidence
Growing pains affected 36.9% of 1,445 Australian children aged 4 to 6. They ache in both legs in the evening or at night and are gone by the morning, with no limp, swelling or stiffness, and the NHS says they aren't a sign of anything serious. Whether they reach the feet is unsettled: the NHS pages describe the legs, and NHS inform says they don't affect the joints, while a teaching resource for doctors includes the feet and ankles, and definitions vary widely across 145 studies.
Every source agrees on what isn't growing pains: pain in one leg or one joint, pain in the morning, a limp, swelling, or a child who is unwell. Those need a GP.
Sources 29, 10, 30, 31, 32
Sprains, broken bones and stress fracturesStrong evidence
Children sprain their ankles more often than teenagers and adults: 2.85 sprains per 1,000 sessions of sport or activity, against 1.94 in teenagers and 0.72 in adults, across 181 studies that followed people forwards, most often in indoor and court sports. A short checklist, the Ottawa ankle rules, picks out the children over about 5 who need an X-ray: it caught 98.5% of fractures across 12 studies of 3,130 children, and cut X-rays by about a quarter. After an outer ankle injury with a normal X-ray, a magnetic resonance imaging (MRI) scan found a hidden growth plate fracture in only 4 of 135 children aged 5 to 12, and most had sprains; for small, low-risk ankle fractures, a removable brace got more children back to their usual activities by 4 weeks than a cast, in a trial of 104 children.
The NHS says a child who has hurt or may have broken a toe should be seen at an urgent treatment centre or A&E rather than treated at home; broken toes usually heal within 4 to 6 weeks. Stress fractures are uncommon in children's feet: 3.9% of 6,831 US girls aged 9 to 15 had a stress fracture of any bone over 7 years, a little more likely with each extra weekly hour of running, basketball, cheerleading or gymnastics, and in 726 children at a Chinese orthopaedic centre, 83% of stress fractures were in the shin bone and 3.6% in a long bone of the foot.
Sources 13, 33, 34, 35, 36, 17, 18
Arthritis, infection and tumours: rare, with clear signsStrong evidence
Juvenile idiopathic arthritis affects about 70 in 100,000 children (a review of 43 studies) and at least 10,000 young people under 16 in the UK, more girls than boys. It brings swollen, stiff joints that are worse in the morning or after rest, the ankle can be the only joint affected, and heel pain right where the Achilles joins the heel, with morning stiffness or other sore joints, can be arthritis rather than Sever's disease.
Bone infection affected 13 in 100,000 children a year in a Norwegian population study, about 3 times as often under 3, and young children don't always get a high temperature with it; it needs urgent care in hospital. After a nail or other sharp object goes through a shoe into the sole, 6.4% of wounds became infected in a US survey of mostly adults; of 80 children admitted to an Israeli hospital after such wounds, 10 had a bone or joint infection, and those who came to hospital later were more likely to have one.
Bone tumours and leukaemia are rare: about 35 children a year in the UK develop an osteosarcoma and about 30 an Ewing sarcoma. Limb pain was present in 43% of children with leukaemia when it was found, alongside tiredness, paleness, fevers and bruising. That is why bone pain that wakes a child, a lump, or bone pain with looking pale, bruising or weight loss needs a GP, and NICE asks GPs to offer a very urgent blood test, and to consider a very urgent X-ray, for persistent or unexplained bone pain in a child.
Sources 37, 19, 3, 16, 7, 8, 38, 39, 40, 41, 42, 43
When a scan or test helpsEmerging evidence
Most children need none. Sever's disease is recognised from the story and a heel squeeze: routine X-rays found another cause in 5 of 98 children with typical symptoms and changed the diagnosis in 1 of 61, and children's physiotherapists say imaging is not usually needed unless other conditions need ruling out. Flat feet and growing pains are recognised from how they look and behave.
Tests answer specific questions: an X-ray after an ankle or midfoot injury when the Ottawa ankle rules say so; a hurt toe in a child checked at an urgent treatment centre or A&E; X-rays for suspected Köhler's or Freiberg's disease, a stiff flat foot or a stress fracture, sometimes followed by an MRI scan; ultrasound or MRI when arthritis is suspected, because foot and ankle X-rays were normal in 40% of children who had it; blood tests, an X-ray and an MRI scan in hospital for a suspected bone or joint infection; and a very urgent blood test for persistent or unexplained bone pain.
Sources 44, 45, 20, 33, 36, 46, 38, 43
How it usually goesEmerging evidence
Most foot and ankle problems improve within 6 weeks, NHS inform says, with the biggest change in the first couple of weeks. Sever's disease can come and go while a child grows and stops once the heel's growth plate closes; the pain often goes within a few months, though some symptoms last 12 to 24 months, and it can come back with another growth spurt. In one older series, all 85 children were back in their sport 2 months after diagnosis.
Köhler's disease lasts months, and the long-term outcome is good whatever the treatment; a short walking cast may shorten the symptoms. Warts and verrucas cleared by themselves at about 52 per 100 children a year in a Dutch school study. Most sprains feel better after 2 weeks, though the NHS advises avoiding strenuous exercise such as running for up to 8 weeks, and a bone infection treated within 3 to 5 days of starting often clears up completely. No one can promise a timescale.
Sources 1, 11, 20, 47, 22, 9, 48, 49, 50, 8
