Pediatric Flatfoot Deformity Case Study Evaluation and Management Frank A Luckino III DPM, Jeffrey C. Lupica DPM, Allan Boike DPM Department of Podiatry

Pediatric flatfoot is not an uncommon patient presentation in clinical practice. A thorough history and physical examination of these children is Treatment of pediatric pes planus depends on the degree of deformity and Parents often become more concerned than the children themselves. Reports paramount. Standing exam and gait analysis is recommended. Body symptomatology. Initial treatment should consist of modifying activity and non- show that more than 30% of all newborns have a calcaneal valgus foot habitus and limb alignment should be noted as well (1). Radiographs in a steroidal anti-inflammatory medications as necessary (2). Stretching regimens deformity of both feet (5). As these individuals mature, the majority will weight-bearing fashion should be obtained (5). As a clinician, one needs to may be implemented if an equinus deformity is a cause for abnormal pronation become asymptomatic and not necessitate care. However, some patients will determine whether the deformity is pathologic or non-pathologic, rigid or and subsequent pes planus. Physical therapy should be started when muscle require conservative and or surgical treatment. The goal of the clinician is flexible, functional or nonfunctional, symptomatic or asymptomatic (1). weakness is observed. Orthotics, whether over-the counter or custom made, determine whether the deformity is rigid or flexible, painful or non-painful, and A calcaneovalgus foot deformity presents with a flexible, deformity which is may provide some relief despite limited level one studies (1). In an article by functional versus nonfunctional. Differential diagnosis includes calcaneal easily manipulated. The foot can be easily dorsiflexed and plantarflexed Evans in 2008, three randomized controlled studies were analyzed that valgus, congenital vertical talus, flexible flatfoot, accessory navicular, tarsal against the leg and subtalar joint range of motion is normal. This deformity evaluated the effect of foot orthoses on the pediatric flatfoot. One study showed coalition, and skewfoot. We present the case of a 5 year old male who is usually asymptomatic. Musculotendinous structures are normal in that children with juvenile rheumatoid arthritis treated with orthoses had a presented to our clinics with chronic foot pain and severe flatfoot deformity. length. There are no associated dislocations and is thought to result from reduction in pain and improved quality of life. Two other studies of children with The patient had no previous neuromuscular disorders or significant past intrauterine position. Orthotics and bracing may help alleviate symptoms typical pes planus and/or pronated foot type treated with orthoses versus medical history. The clinical and radiographic findings are reported and (5). Congenital vertical talus (CVT), typically presents with a symptomatic controls showed no significant difference in regards to foot type, motor skills, or treatment plan is outlined. deformity that is rigid in nature. “Rocker-bottom” appearance is common physical performance. However, the latter two studies did show a reduction in to the foot and is not amenable to reduction. The navicular is dorsally leg/foot pain though this was more of an observed rather than quantified result dislocated on the talus. The Achilles tendon is typically contracted (8). As reported in a Cochran Review orthotics should not be used in children posteriorly and extensor digitorum longus anteriorly. Treatment usually that have a asymptomatic flexible flatfoot as the deformity will reduce with age. consists of casting followed by surgery when conservative treatment fails Orthotics should only be used in children that are symptomatic. Referenced in (6). Stressed plantarflexion/dorsiflexion views are paramount in this same article, children who wear shoe gear often before the age of six have differentiating tarsal coalition, CVT, pediatric flexible flatfoot (1). a higher preponderance for a pes planus foot type than there unshod counterparts (4). On physical exam, vascular status was intact and neurological exam was normal. Dermatological exam revealed no relevant findings. On the Discussion: musculoskeletal exam, muscle strength was rated 5/5. Ankle joint ROM was Pediatric flatfoot deformity is an entity commonly seen in orthopedic and decreased with the knee flexed but full when extended. All other joints are full podiatric practices alike. It is the clinician’s role to inform concerned parents and without pain or crepitus bilateral. Standing exam reveals bilateral pes that the majority of children will have a pes planus foot type that should resolve planus with an everted rear foot of approximately 15 degrees. Standing exam with time. Evans et al reported that half of all young children with have a flatfoot also reveals medial talar bulge and bilateral genu recurvatum. Patient is but this number will reduce by 50% as these patients mature (4). The majority unable to perform single leg heel rise on either limb. Patient has difficulty with of patients will not need to be treated but those that do may require double limb heel rise. Normal ROM to the knee and hip. conservative and/or surgical correction. The clinician must always be aware of Radiographs reveal no fractures or dislocations. Bone stock is adequate. pathologic flatfoot deformities that may be debilitating if left untreated. As for Primary and secondary centers of ossification are adequate for patient age conservative treatment, there is a lack of randomized controlled studies in and sex. Anterior-posterior and lateral radiographs reveal signs of pronation: regards to orthoses for the treatment of the pes planus foot type. Orthotics are talar head uncovering, increased talar declination angle, decreased calcaneal not recommended for asymptomatic flatfoot patients but may be useful for inclination, increased meary’s angle, and an anterior break in the cyma line. those that are having symptomatology. Surgical correction may be warranted Review of the patients past medical history reveals occasional constipation but No signs of an apparent coalition. Plantarflexed, lateral views reveal the talus for those that fail conservative treatment. otherwise unremarkable. Review of systems is noncontributory to the chief realigning with the 1st metatarsal declination angle. The patient was diagnosed REFERENCES: complaint. The patient underwent a complete, lower extremity physical exam with calcaneovalgus, pes planus, gastrocnemius equinus, and ligamentous 1. Yeagerman SE, Cross MB, Positano R, Doyle SM. Evaluation and Tarsal coalition can also present as a rigid flatfoot. The coalition may be which included a neurovascular, dermatological, and musculoskeletal workup. laxity. The etiology and diagnosis were discussed with the patient and the treatment of symptomatic pes planus. Cur Opin Pediatr 23: 60-67, 2011. osseous, fibrous, or cartilaginous. Talocalcaneal and calcaneonavicular The child was examined both weight-bearing and non weight-bearing. Bilateral mother. The patient was treated with bilateral University of California Berkley 2. Harris EJ, Vanore JV, Thomas JL, Kravitz SR, Mendelson SA, Mendicino coalitions are most common. Decreased subtalar joint range of motion is radiographs were taken which included anterior-posterior, lateral, and Laboratory foot orthoses. Surgical intervention was discussed with the patient RW, Silvani SH, Gassen SC. Diagnosis and treatment of pediatric flatfoot. J present with pain associated with inversion. Radiographic signs may include plantarflexed-lateral views. Photographs of the patient were taken as well in an if conservative therapy fails. Foot Ankle Surg 43: 341-370, 2004. talar beaking, absent middle facet, ‘C-sign’, anteater nose sign, rounding of anterior and posterior direction. 3. Pfeiffer M, Kotz R, Ledl T, Hauser G, Sluga M. Prevalence of flatfoot in LITERATURE REVIEW: the lateral process of the talus, narrowing of the posterior facet of the subtalar preschool-aged children. J Pediatr 118: 634-639, 2006. Pes planus, or flat foot, is described as a flattening of the medial joint, and/or a ball and socket ankle joint (7). CT scan is the gold standard for 4. Evans AM, Rome K. A Cochrane review of the evidence for non-surgical longitudinal arch, with or without an associated heel valgus (1). diagnosis (1). interventions for flexible pediatric flatfeet. Eur J Phys Rehabil Med 47: 69-89, Pediatricians and parents are often the first to become aware of the Accessory navicular typically presents with an asymptomatic flexible foot 2011. pathology (2). It is a common entity often seen in newborns and young that may or may not have an associated pes planus depending on the 5. Sullivan JA. Pediatric flatfoot: Evaluation and Management. J Amer Acad children. In a study by Pfeiffer et al in 2006, the prevalence of pes planus pull of the posterior tibial tendon. Patients that are symptomatic will have Ortho Surg 7: 44-53, 1999. in school children three to six years of age was 44%. The percentage tenderness and erythema over the navicular tuberosity (1) and pain with 6. Mckie J, Ramdomisli T. Congenital vertical talus: A review. Clin Podiatr decreased significantly as the age of the child increased. Flat foot type resistance against inversion. Lateral oblique radiographs are typically Med Surg 27: 145-156, 2010. was seen more often in boys who were younger in age and more obese diagnostic (5). (3). Skew foot (serpentine, “Z”, or “S” shaped foot) presents with a flatfoot 7. Rodriguez N, Choung DJ, Dobbs MB. Rigid pediatric pes planovalgus: Etiology includes neurological (i.e. cerebral palsy), muscular (i.e. deformity with a valgus orientation of the heel, displacement laterally of the conservative and surgical treatment options. Clin Podiatr Med Surg 27: muscular dystrophy), genetic (i.e. osteogenesis imperfecta, Marfan’s navicular on the talus, and adductus of the forefoot. Etiology is unknown. This 79-92, 2010. syndrome, Down’s syndrome), or collagen (i.e. ligamentous laxity). Other may be a residual pathology secondary to cast treatment for club foot and 8. Evans AM. The flatfooted child- To treat or not to treat. JAPMA 98: causes include tarsal coalition, skew foot, trauma, infection, equinus, metatarsus adductus deformities. Casting and manipulation should be 386-393, 2008. accessory navicular, or calcaneal valgus (4). attempted initially followed by surgical intervention (5).