Pediatric Flatfoot Deformity Case Study
Evaluation and Management
Frank A Luckino III DPM, Jeffrey C. Lupica DPM, Allan Boike DPM
Pediatric flatfoot is not an uncommon patient presentation in clinical practice.
Parents often become more concerned than the children themselves. Reports
show that more than 30% of all newborns have a calcaneal valgus foot
deformity of both feet (5). As these individuals mature, the majority will
become asymptomatic and not necessitate care. However, some patients will
require conservative and or surgical treatment. The goal of the clinician is
determine whether the deformity is rigid or flexible, painful or non-painful, and
functional versus nonfunctional. Differential diagnosis includes calcaneal
valgus, congenital vertical talus, flexible flatfoot, accessory navicular, tarsal
coalition, and skewfoot. We present the case of a 5 year old male who
presented to our clinics with chronic foot pain and severe flatfoot deformity.
The patient had no previous neuromuscular disorders or significant past
medical history. The clinical and radiographic findings are reported and
treatment plan is outlined.
Review of the patients past medical history reveals occasional constipation but
otherwise unremarkable. Review of systems is noncontributory to the chief
complaint. The patient underwent a complete, lower extremity physical exam
which included a neurovascular, dermatological, and musculoskeletal workup.
The child was examined both weight-bearing and non weight-bearing. Bilateral
radiographs were taken which included anterior-posterior, lateral, and
plantarflexed-lateral views. Photographs of the patient were taken as well in an
anterior and posterior direction.
Department of Podiatry
On physical exam, vascular status was intact and neurological exam was
normal. Dermatological exam revealed no relevant findings. On the
musculoskeletal exam, muscle strength was rated 5/5. Ankle joint ROM was
decreased with the knee flexed but full when extended. All other joints are full
and without pain or crepitus bilateral. Standing exam reveals bilateral pes
planus with an everted rear foot of approximately 15 degrees. Standing exam
also reveals medial talar bulge and bilateral genu recurvatum. Patient is
unable to perform single leg heel rise on either limb. Patient has difficulty with
double limb heel rise. Normal ROM to the knee and hip.
Radiographs reveal no fractures or dislocations. Bone stock is adequate.
Primary and secondary centers of ossification are adequate for patient age
and sex. Anterior-posterior and lateral radiographs reveal signs of pronation:
talar head uncovering, increased talar declination angle, decreased calcaneal
inclination, increased meary’s angle, and an anterior break in the cyma line.
No signs of an apparent coalition. Plantarflexed, lateral views reveal the talus
realigning with the 1st metatarsal declination angle. The patient was diagnosed
with calcaneovalgus, pes planus, gastrocnemius equinus, and ligamentous
laxity. The etiology and diagnosis were discussed with the patient and the
mother. The patient was treated with bilateral University of California Berkley
Laboratory foot orthoses. Surgical intervention was discussed with the patient
if conservative therapy fails.
LITERATURE REVIEW:
Pes planus, or flat foot, is described as a flattening of the medial
longitudinal arch, with or without an associated heel valgus (1).
Pediatricians and parents are often the first to become aware of the
pathology (2). It is a common entity often seen in newborns and young
children. In a study by Pfeiffer et al in 2006, the prevalence of pes planus
in school children three to six years of age was 44%. The percentage
decreased significantly as the age of the child increased. Flat foot type
was seen more often in boys who were younger in age and more obese
(3).
Etiology includes neurological (i.e. cerebral palsy), muscular (i.e.
muscular dystrophy), genetic (i.e. osteogenesis imperfecta, Marfan’s
syndrome, Down’s syndrome), or collagen (i.e. ligamentous laxity). Other
causes include tarsal coalition, skew foot, trauma, infection, equinus,
accessory navicular, or calcaneal valgus (4).
A thorough history and physical examination of these children is
paramount. Standing exam and gait analysis is recommended. Body
habitus and limb alignment should be noted as well (1). Radiographs in a
weight-bearing fashion should be obtained (5). As a clinician, one needs to
determine whether the deformity is pathologic or non-pathologic, rigid or
flexible, functional or nonfunctional, symptomatic or asymptomatic (1).
A calcaneovalgus foot deformity presents with a flexible, deformity which is
easily manipulated. The foot can be easily dorsiflexed and plantarflexed
against the leg and subtalar joint range of motion is normal. This deformity
is usually asymptomatic. Musculotendinous structures are normal in
length. There are no associated dislocations and is thought to result from
intrauterine position. Orthotics and bracing may help alleviate symptoms
(5). Congenital vertical talus (CVT), typically presents with a symptomatic
deformity that is rigid in nature. “Rocker-bottom” appearance is common
to the foot and is not amenable to reduction. The navicular is dorsally
dislocated on the talus. The Achilles tendon is typically contracted
posteriorly and extensor digitorum longus anteriorly. Treatment usually
consists of casting followed by surgery when conservative treatment fails
(6). Stressed plantarflexion/dorsiflexion views are paramount in
differentiating tarsal coalition, CVT, pediatric flexible flatfoot (1).
Tarsal coalition can also present as a rigid flatfoot. The coalition may be
osseous, fibrous, or cartilaginous. Talocalcaneal and calcaneonavicular
coalitions are most common. Decreased subtalar joint range of motion is
present with pain associated with inversion. Radiographic signs may include
talar beaking, absent middle facet, ‘C-sign’, anteater nose sign, rounding of
the lateral process of the talus, narrowing of the posterior facet of the subtalar
joint, and/or a ball and socket ankle joint (7). CT scan is the gold standard for
diagnosis (1).
Accessory navicular typically presents with an asymptomatic flexible foot
that may or may not have an associated pes planus depending on the
pull of the posterior tibial tendon. Patients that are symptomatic will have
tenderness and erythema over the navicular tuberosity (1) and pain with
resistance against inversion. Lateral oblique radiographs are typically
diagnostic (5).
Skew foot (serpentine, “Z”, or “S” shaped foot) presents with a flatfoot
deformity with a valgus orientation of the heel, displacement laterally of the
navicular on the talus, and adductus of the forefoot. Etiology is unknown. This
may be a residual pathology secondary to cast treatment for club foot and
metatarsus adductus deformities. Casting and manipulation should be
attempted initially followed by surgical intervention (5).
Treatment of pediatric pes planus depends on the degree of deformity and
symptomatology. Initial treatment should consist of modifying activity and non-
steroidal anti-inflammatory medications as necessary (2). Stretching regimens
may be implemented if an equinus deformity is a cause for abnormal pronation
and subsequent pes planus. Physical therapy should be started when muscle
weakness is observed. Orthotics, whether over-the counter or custom made,
may provide some relief despite limited level one studies (1). In an article by
Evans in 2008, three randomized controlled studies were analyzed that
evaluated the effect of foot orthoses on the pediatric flatfoot. One study showed
that children with juvenile rheumatoid arthritis treated with orthoses had a
reduction in pain and improved quality of life. Two other studies of children with
typical pes planus and/or pronated foot type treated with orthoses versus
controls showed no significant difference in regards to foot type, motor skills, or
physical performance. However, the latter two studies did show a reduction in
leg/foot pain though this was more of an observed rather than quantified result
(8). As reported in a Cochran Review orthotics should not be used in children
that have a asymptomatic flexible flatfoot as the deformity will reduce with age.
Orthotics should only be used in children that are symptomatic. Referenced in
this same article, children who wear shoe gear often before the age of six have
a higher preponderance for a pes planus foot type than there unshod
counterparts (4).
Discussion:
Pediatric flatfoot deformity is an entity commonly seen in orthopedic and
podiatric practices alike. It is the clinician’s role to inform concerned parents
that the majority of children will have a pes planus foot type that should resolve
with time. Evans et al reported that half of all young children with have a flatfoot
but this number will reduce by 50% as these patients mature (4). The majority
of patients will not need to be treated but those that do may require
conservative and/or surgical correction. The clinician must always be aware of
pathologic flatfoot deformities that may be debilitating if left untreated. As for
conservative treatment, there is a lack of randomized controlled studies in
regards to orthoses for the treatment of the pes planus foot type. Orthotics are
not recommended for asymptomatic flatfoot patients but may be useful for
those that are having symptomatology. Surgical correction may be warranted
for those that fail conservative treatment.
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