Chronic Non-Traumatic Dorsolateral Foot Pain in Children
Most Likely Diagnosis
Tarsal coalition is the primary diagnosis to consider for chronic non-traumatic dorsolateral foot pain in a child that is non-tender on palpation and worsens with walking. 1
Differential Diagnosis
Primary Considerations
Tarsal coalition: This bony or fibrous connection between tarsal bones classically presents with dorsolateral foot pain that worsens with activity and walking 1. The pain is typically not tender to palpation initially, though a rigid flatfoot may develop over time 2. Calcaneonavicular coalitions are most easily detected and account for the dorsolateral location 1.
Stress fracture: Progressive worsening pain following increased activity or change to harder walking surfaces suggests stress fracture 3, 4. However, stress fractures typically demonstrate point tenderness on palpation, which contradicts your presentation 3.
Köhler's disease (navicular avascular necrosis): This rare condition affects the navicular bone and can cause dorsolateral midfoot pain in children 2, 5. The foot may appear normal initially, and treatment is always conservative 2.
Secondary Considerations
Accessory navicular: Can cause medial to dorsolateral midfoot pain, though typically demonstrates tenderness over the prominence 5.
Sinus tarsi syndrome: May cause lateral hindfoot pain but usually follows trauma and demonstrates tenderness in the sinus tarsi region 3.
Systemic inflammatory conditions: Bilateral symptoms or pain in multiple joints should raise concern for juvenile idiopathic arthritis or other arthritides 6, 3, 2.
Diagnostic Approach
Clinical Examination
Palpate specific anatomical landmarks: Focus on the lateral calcaneal wall, sinus tarsi, calcaneocuboid joint, and calcaneonavicular region to localize pathology 3, 4.
Assess for rigid flatfoot: Tarsal coalition may present with progressive loss of subtalar motion and development of rigid flatfoot deformity 2.
Perform calcaneal compression test: Squeeze the calcaneus medially to laterally; pain suggests stress fracture (though this typically causes tenderness) 3, 4.
Evaluate gait pattern: Antalgic gait with pain on weight-bearing is characteristic of structural pathology 1.
Initial Imaging
Obtain weight-bearing radiographs of the foot as the first imaging study. 1
Radiographs demonstrate 80-100% sensitivity and 97-98% specificity for calcaneonavicular coalitions 1.
Lateral and oblique views are essential for detecting calcaneonavicular coalitions 1.
Secondary signs on lateral view may suggest subtalar coalition with 100% sensitivity and 88% specificity 1.
Advanced Imaging
If radiographs are negative but pain persists beyond one week, obtain MRI without contrast or CT without contrast as equivalent alternatives. 6, 3
MRI or CT confirms tarsal coalitions on sagittal views 1.
Technetium bone scanning may be considered for suspected stress fracture with negative radiographs 6, 3.
Management Algorithm
Conservative Treatment (First-Line)
Activity modification: Reduce high-impact activities and weight-bearing stress 6, 4.
Footwear optimization: Well-cushioned athletic shoes to reduce impact forces 6.
NSAIDs: Naproxen 250-500 mg twice daily or ibuprofen for pain control 6, 4.
Immobilization: Consider short-term immobilization (3-5 days maximum) for acute exacerbations, then commence active exercise 4.
Referral Indications
Refer to pediatric orthopedics or podiatric foot and ankle surgery if: 6, 4
- No improvement after 6-8 weeks of conservative treatment
- Advanced imaging reveals tarsal coalition requiring surgical consideration
- Progressive rigid flatfoot deformity develops
- Neurologic symptoms emerge (burning, tingling, numbness)
Critical Pitfalls to Avoid
Do not overlook tarsal coalition: Standard foot radiographs may miss subtalar coalitions due to overlapping structures; secondary signs on lateral view are crucial 1.
Do not assume mechanical etiology with bilateral symptoms: Evaluate for underlying rheumatic disease or systemic inflammatory conditions 4, 2.
Do not maintain prolonged immobilization: Beyond 3-5 days, complete immobilization causes muscular atrophy and worsens functional outcomes 4.
Reexamine at 3-5 days post-presentation: Initial examination may be limited by pain and guarding; repeat assessment provides clearer findings 3, 4.