pediatric housecalls Robert R. Jarrett M.D. M.B.A. FAAP

Leg Cramps In Children

[A grandma wonders about her grandson’s leg cramps which his doctor couldn’t diagnose with a ‘blood test.’]

My grandson has severe leg pain [leg cramps] which stops him from playing at all times of the day. It doesn’t just happen in the calf of his leg but also in the upper part of his leg. He does have flat feet. The doctor did blood work and said there was nothing wrong. I know they need to trust their doctor but I worry that there might be something really wrong… Robyn C

Yes there most definitely is a problem, and one that could create even substantial lifestyle impairment. There are, however, definite ways parents and grandparents can help.

You didn’t mention how old your grandson is or what type of training the doctor he visited had (i.e. family doctor, nurse practitioner or board-certified Pediatrician etc.); but, when pediatricians see a child with leg pain the first thing they think of (also the first things people expect them to think of) are metabolic and other myelophthisic (cancer-like) problems – which, although uncommon are pretty bad.

Probably, when he says “there’s nothing wrong” he means there is nothing that he/she considers “serious,” wrong – a good thing.

But trained pediatricians know that children are NOT supposed to have leg aches under normal physical activities; and, definitely not recurring. Of course when they have done “two-a-days” in sports one would expect muscle soreness from lactic acid build up; but that resolves readily and makes the muscle “stronger” for greater endurance the next time.

Most likely “pes valgo planus” (PVP) or what most people call “flat feet” is the issue. I say that even without seeing him merely because nine times out of ten that’s what it is; and the symptoms you describe are just so completely classic of the problem.

If the condition is substantial, the motion dynamics in the feet are so out of balance that compensating muscle groups are overused just to maintain normal posture and balance.

Then, when they are further stressed by sports or other activities they are very painful. In “flat feet” the muscles do get “stronger” but only so far and usually not enough to erase the pain.

You may have already gotten some hints in the way he behaves and his preferences. Does he prefer to go without shoes – or does at least “some support” help? Most children with PVP do recognize, even subconsciously, that their feet feel better in shoes with good arch support.

Does he try to run but gives the impression that he’s frustrated because he can’t do it without discomfort? Does he rub his feet or legs from being sore? Does he feel he can’t keep up with others or isn’t as “good” as they are?

Does he awaken in the night with leg cramps or pain in his legs and feel relief when they are massaged? Do you notice him starting to shy away from “active” play which uses his lower extremities – even prefer being “indoors” and sitting?

Has changing shoes helped somewhat? For example does he have less or more pain when wearing “Sunday shoes” (firm leather support with an arch support); or “good” sport shoes with a substantial arch support; or, even better, cowboy boots (which usually have the best arch support of all these days.) None of these have enough of an arch to “correct” the problem fully but a little usually helps some.

Many “children’s doctors” (and even some certified Pediatricians) stop after the workup for the “bad” things and may even call a child’s complaints “growing pains.” Of course there is no such thing.

Fortunately, most parents don’t need a physician to diagnose “flat feet” – when looking at the bare feet the arch seems to “collapse” toward the floor and the toes turn (“splay”) outward. It may not always be possible to compare the child’s feet with their parents or siblings because the condition does run in families and they are frequently flat as well.

I usually advise parents with children who have symptoms from PVP to try cowboy boots first. They are readily available (without a prescription), fairly inexpensive and often make a great deal of difference. They often become the child’s favorite footwear everywhere.

If they work sufficiently that’s great because they can be replaced as the child grows fairly easily. If they work but insufficiently then custom fitted orthotics are the next step which can pose some issues depending where you live and the practice/skills of the doctors available.

Orthotics are basically shoe inserts which provide correction to the arch and thus support the whole lower leg and hips back into more normal position. They are simple pieces of several kinds of material which have been molded into a specific shape and contour needed by an individual foot. There are few standards in their construction although it does take some amount of knowledge and experience to make them.

In the past, they have largely been available through a consult with a podiatrist foot specialist who has casted, and molded, and fitted, and xray’d and charged insurance companies a fair amount of money for all that work. The past few years orthotics have become available over the internet – perhaps because there is a large profit margin; but, that introduces a great amount of impersonalization with the problems that brings.

Here are some bullet points I’ve discovered over the years trying to assist children and their parents to get some help and relief:

• Cowboy boots are the best initial trial. Taping is difficult and almost impossible to do correctly and doesn’t remain fixed long enough for a child to even tell there’s a difference.
• Chiropractic massaging and twisting does nothing to fix the problem – it can’t.
• Orthotics do need to be sized with enough correction for each specific child’s needs; but, it’s not like the astronaut’s form fitted couch no matter what a doctor wants you to believe. Think similar to shoe sizes with five or six heights each.
• In order to do their job, orthotics put pressure on the arch upwards, so they do cause some initial discomfort when getting used to them. The material they are constructed with is crucial. NO hard plastic, NO thick leather, NO crushable foam. A firm but pliable, rubber-like compound is easier to endure, corrects better, lasts longer and is cheaper in the long run.
• Let’s say this: the actual orthotic, in a commodities based, free-market system would cost a great deal less than any of us will be able to buy them for in the U.S., unless we know how to make them ourselves and get all the angles right. Think a thousand percent markup.
• The amount of pain relief seems to be related to the arch angle built into the orthotic – called the “Theta” angle. That’s a good term to use to “Google” for orthotics.

When I was in private practice I was often disappointed with results when I referred them to orthopods and podiatrists and found that there was a huge difference in the skill and expertise of the various foot specialists in my town. I finally resorted to referring to only a couple of podiatrists which had decent results and kept to readily accepted principles.

We now realize that the material with which the orthotics are made AND the “Theta” angle built in to them are the two most significant factors in their comfort, compliance, use and pain resolution.

I hope that this has helped a bit — Please let me know if I can help further or you would like any further
references.

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