Common Pediatric Foot Deformities
Steve Min M.D.
PGY-1
May 2002
Anatomy/Terminology
•3 main sections
1.Hindfoot – talus,
calcaneus
2.Midfoot – navicular,
cuboid, cuneiforms
3.Forefoot –
metatarsals and
phalanges
Anatomy/Terminology
• Important joints
1. tibiotalar (ankle) – plantar/dorsiflexion
2. talocalcaneal (subtalar) – inversion/eversion
• Important tendons
1. achilles (post calcaneus) – plantar flexion
2. post fibular (navicular/cuneiform) – inversion
3. ant fibular (med cuneiform/1st met) – dorsiflexion
4. peroneus brevis (5th met) - eversion
Anatomy/Terminology
• Varus/Valgus
Calcaneovalgus foot
Calcaneovalgus foot
• ankle joint dorsiflexed, subtalar joint everted
• classic positional deformity
• more common in 1st born, LGA, twins
• 2-10% assoc b/w foot deformity and DDH
• treatment requires stretching: plantarflex
and invert foot
• excellent prognosis
Congenital Vertical Talus
• true congenital deformity
• 60% assoc w/ some neuro impairment
• plantarflexed ankle, everted subtalar joint, stiff
• requires surgical correction (casting is
generally ineffective)
Talipes Equinovarus (congenital clubfoot)
A. General
- complicated, multifactorial deformity of
primarily genetic origin
- 3 basic components
(i) ankle joint plantarflexed/equines
(ii) subtalar joint inverted/varus
(iii) forefoot adducted
Talipes Equinovarus (congenital clubfoot)
Talipes Equinovarus (congenital clubfoot)
B. Incidence
- approx 1/1,000 live births
- usually sporadic
- bilateral deformities occur 50%
C. Etiology
- unknown
- ?defect in development of talus leads to
soft tissue changes in joints, or vice
versa
Talipes Equinovarus (congenital clubfoot)
D. Diagnosis/Evaluation
- distinguish mild/severe forms from other disease
- AP/Lat standing or AP/stress dorsiflex lat films
E. Treatment
• Non-surgical
- weekly serial manipulation and casting
- must follow certain order of correction
- success rate 15-80%
• Surgical
- majority do well; calf and foot is smaller
Talipes Equinovarus (congenital clubfoot)
Pes Planus (flatfoot)
A. General
- refers to loss of normal medial long. arch
- usually caused by subtalar joint assuming an
everted position while weight bearing
- generally common in neonates/toddlers
B. Evaluation
- painful?
- flexible? (hindfoot should invert/dorsiflex
approx 10 degrees above neutral
- arch develop with non-weight bearing pos?
Pes Planus (flatfoot)
Pes Planus (flatfoot)
C. Treatment
(i) Flexible/Asymptomatic
- no further work up/treatment is necessary!
- no studies show flex flatfoot has increased
risk for pain as an adult
(ii) rigid/painful
- must r/o tarsal coalition – congenital fusion or
failure of seg. b/w 2 or more tarsal bones
- usually assoc with peroneal muscle spasm
- need AP/lat weight bearing films of foot
In-Toeing
A. General
- common finding in newborns and children
- little evidence to show benefit from treatment
In-Toeing
B. Evaluation
- family hx of rotational deformity?
- pain?
- height/weight normal?
- limited hip abduct or leg length discrepancy?
- neuro exam
C. 3 main causes
(i) metatarsus adductus
(ii) internal tibial torsion
(iii) excessive femoral anteversion
In-Toeing
(i) metatarsus adductus
- General
• normal hindfoot,
medially deviated
midfoot
• diagnosis made if
lateral aspect of foot
has “C” shape, rather
than straight
In-Toeing
(i) metatarsus adductus
- Evaluation
• should have normal
ankle motion
• assess flexibility by
holding heel in
neutral position,
abducting forefoot
In-Toeing
(i) metatarsus adductus
• treatment
- if flexible, stretching; Q diaper change, 10 sec
- if rigid, or if no resolution by 4-8 months,
refer to ortho
- prognosis is good: 85-90% resolve by 1yr
In-Toeing
(ii) Internal Tibial Torsion
• usually presents by
walking age
• knee points forward,
while feet point
inward
In-Toeing
(ii) Internal Tibial Torsion
• Treatment
- reassurance! spontaneous resolution in 95%
children, usually by 7-8yrs
- controversy with splints, casts, surgery
In-Toeing
(iii) Excessive Femoral Anteversion
• both knees and feet
point inward
• presents during early
childhood (3-7yrs)
• most common cause
of in-toeing
In-Toeing
(iii) Excessive Femoral Anteversion
• int rotation 70-80 deg
ext rotation 10-30 deg
• “W” position
In-Toeing
(iii) Excessive Femoral Anteversion
• increase in internal
rotation early with
gradual decrease
In-Toeing
(iii) Excessive Femoral Anteversion
• Treatment
- no effective non-surgical treatment
- surgical intervention usually indicated if
persists after 8-10 yrs and is cosmetically
unacceptable or functional gait problems
- derotational osteotomy
References
• Hoffinger SA. Evaluation and Management of Pediatric
Foot Deformities. Pediatric Clinics of North America. 1996.
43(5):1091-1111
• Yamamoto H. Nonsurgical treatment of congenital clubfoot
with manipulation, cast, and modified Denis Browne splint.
J Pediatric Ortho. 1998. 18(4): 538-42
• Sullivan JA. Pediatric flatfoot: evaluation and management.
J Am Acad Orthop Surg 1999. 7(1): 44-53
• Dietz FR. Intoeing-Fact, Fiction and Opinion. American
Family Physician. 1994. 50(6): 1249-1259
• Canale. Campbell’s Operative Orthopedics, 9th ed. 1998
1713-1735; 938-940
