Pediatric Foot Deformities (2023)

MetatarsusAdductus

Metatarsusadductus describes a congenital deformity in which the forefoot is turnedinward relative to the hindfoot (Figure 1). Metatarsus adductus may be"flexible" (the foot can be straightened by the examiner’s hand) or"nonflexible" (in which the foot cannot be straightened by hand).

Figure 1: A drawing showing a “C”-shaped or bean-shaped foot characteristic of metatarsus adductus.

Theforefoot comprises the 5 metatarsal bones and 14 phalangeal bones. Inmetatarsus adductus, these bones are deviated medially. Thus, the inside borderof the foot is concave, the outside or lateral border of the foot is convex,while the hindfoot remains in a relatively neutral position. The angulation isat the tarsometatarsal joint.

Metatarsusadductus is usually noted soon after birth, but can present at any age. Commonly,the parents or pediatrician of a child with metatarsus adductus will notice in-toeingincidentally. Parents may also comment regarding a wider gap between the firstand second toes. This often suggests a mild flexible deformity that is observedto actively correct when the lateral border of the foot is tickled.

Theexact cause of metatarsus adductus is not known, but it is thought to be a“packaging” disorder, or a result of positioning inside the uterus.

Metatarsusadductus is the most common congenital foot deformity occurring inapproximately 1 of every 1000 live births, with equal frequency in males andfemales.Metatarsusadductus is bilateral in approximately 50% of cases.

Metatarsusadductus is defined on clinical examination by the heel bisector line. Todetermine this, a line is drawn on the plantar foot starting from the center ofthe heel directly vertical past the toes. In normal alignment, this line willexit the forefoot through the second webbed space, between the 2ndand 3rd toes (Figure 2). In metatarsus adductus, the line will exitmore laterally in the forefoot. The greater the number of toes on the same sideof the line as the great toe, the more severe the metatarsus adductus.

Forpatients presenting with in-toeing, one must also examine for and considerfemoral anteversion and internal tibial torsion (seePediatric Lower Limb Deformities). Another foot deformity called skew foot also presentswith adduction of the forefoot, but unlike metatarsus adductus there areadditional deformities of the midfoot in abduction and hindfoot valgus. Congenitalhallux varus differs from metatarsus adductus in that the medial deviation isisolated to the great toe.

Thereis always full range of motion of the ankle and subtalar joint with metatarsus adductus.Stiffness in these areas should lead the examiner to consider other diagnoses.

Figure 2. The heel bisector line identifies the severity of metatarsus adductus.

AlthoughX-rays are not usually necessary to evaluate metatarsus adductus, they arerecommended in the case of nonflexible metatarsus adductus, and in older children.

Inthe majority of cases, metatarsus adductus is mild and flexible. This willimprove over time, up to about 4 years of age. Parents can perform stretchingand stimulation of the foot.

Ifthe metatarsus adductus is only partly flexible or rigid, serial stretchingcasts are sometimes necessary to achieve correction. Parents can be reassuredthat good results are expected with mild or moderate deformity and nofunctional limitations. It is rare that surgery is needed for correction ofmetatarsus adductus, reserved for the most severe rigid cases or casesresistant to serial casting. Soft tissue releases of the abductor hallucis andthe first tarsometatarsal joint capsule followed by more casting may beindicated. If a child is older with rigid adductus osteotomies may beconsidered.

Metatarsusadductus is associated with other presumed packing deformities like torticollisand developmental dysplasia of the hip. It is important to examine the entirechild when they present with a congenital foot deformity. Risk factors includetwin pregnancy or oligohydramnios.

TarsalCoalition

Tarsalcoalition describes the abnormal connection between two or more tarsal bonesthat limits range of motion and causes a rigid flat foot.

Thereare seven tarsal bones. These include the talus, calcaneus, navicular, cuboid,and the three cuneiforms, the medial, middle (or intermediate), lateral (see Figure3).

Figure 3. The tarsal bones, as seen from above.

(Video) Paediatric foot deformities

Theabnormal connection between these bones may be composed of bone, fibrous tissueor cartilaginous tissue. This occurs embryologically due to failure ofsegmentation. Any abnormal connection between the tarsal bones can result indecreased range of motion of the subtalar joint, thereby limiting inversion andeversion of the heel.

Clinically,a tarsal coalition may present as a rigid flat foot. Patients usually presentwith a chief complaint of pain over the sinus tarsi, an aching pain along theirarch, or pain under their medial malleolus that is worse with activity andalleviated with rest. The most common age for presentation of tarsal coalition isaround 8 to 16 years, typically becoming symptomatic in adolescence. Some childrenmay present with the complaint of recurrent ankle sprains or progressive flatfoot.

Onphysical exam, patients will often have a rigid subtalar joint. This is bestassessed with the foot held in neutral dorsiflexion and then applying aninversion and eversion force to evaluate subtalar motion. With standing toe risethere is no inversion of the hindfoot due to limited subtalar motion. Thosewith calcaneonavicular coalitions often have more preserved motion since thetwo connected bones do not cross the subtalar joint.

Imagingstudies are required for diagnosis of a tarsal coalition. AP, lateral, obliqueand, Harris axial views should be obtained. The Harris view is obtained byhaving the patient stand on the cassette with the x-ray beam angled between 35and 45 degrees and will detect any coalition between the talus and calcaneus.

A calcaneonavicular coalition is best seen on an oblique x-ray of the foot (Figure 4). It may also be noticed on a standing lateral x-ray of the foot, seen as an elongated anterior process of the calcaneus. This is known as the “ant-eater sign.” A talocalcaneal coalition may also be appreciated on the lateral radiograph by a finding known as the “C-sign.” This is a “C” shaped line that is formed by the dome of the talus and the sustentaculum tali of the calcaneus (Figure 4). However, it is important to note that these findings have a low sensitivity, and their absence does not rule out the presence of a tarsal coalition.

Thebest imaging technique to evaluate for tarsal coalition is a CT scan. The CT canalso aide in surgical planning and is used to look for other coalitions ifsurgery is being considered. If the history and physical exam are consistentwith a coalition but the CT scan is non-diagnostic an MRI may reveal a fibrouscoalition.

Figure 4. Calcaneonavicular coalition “ant-eater sign” seen on oblique foot x-ray (arrow).

Figure 5: Subtalar tarsal coalition "C-Sign."

Mostcommonly, tarsal coalitions are seen between the talus and calcaneus, andbetween the calcaneus and the navicular bones. These two combinations account forabout 90 percent of all tarsal coalitions. Other described locations arebetween the talus and navicular, the calcaneus and cuboid, the navicular andcuneiform, and between a cuneiform and metatarsal, however these are uncommon.In about half of cases a tarsal coalition will be present bilaterally.

Inthe case of rigid flat foot, it is also important to consider other causes suchas juvenile idiopathic arthritis, septic arthritis, osteomyelitis, and otherbone lesions for example an osteoid osteoma.

Anyconstitutional symptoms should prompt investigation into one of thedifferential causes of a rigid flatfoot. Pain worse in the morning rather thanafter activities may indicate a rheumatologic cause. There are syndromesassociated with tarsal coalitions such as Apert and Crouzon syndrome and anydysmorphic features should be noted.

Upto 25 percent of tarsal coalitions are thought to become symptomatic, and onlythose that cause symptoms should be treated. First line treatment includessymptom management with activity modification, orthoses, and anti-inflammatoriesas needed. Second line treatment is to try cast immobilization for a period ofabout 4-6 weeks.

Ifnon-operative treatment fails to provide long-term pain relief, surgery can beconsidered. Prior to surgery, a CT scan should be obtained to evaluate for thepresence of a second coalition. Surgery begins with resection of the coalitionwith placement of interposed tissue (muscle or fat) to help prevent itsreformation. If there is a significant foot deformity associated with thecoalition, consideration can also be given to osteotomies for deformitycorrection. In cases where there is degeneration of the joint involved in thecoalition, or if a subtalar coalition is particularly large, a fusion of thejoint is considered; resection in these cases may lead to poorer outcomes.

(Video) PT Level 10 PT for Pediatric and its Surgery PT 5026 Foot deformities

Thereare no preventative measures for tarsal coalition. It is associated withcertain other congenital abnormalities like fibular hemimelia, and syndromic associations.

AccessoryNavicular

Anaccessory navicular is a prominence of the navicular on the plantar medialsurface and is considered a normal variant (Figure 6).

Figure 6: A normal and an accessory navicular (NB: x-ray of an adult foot). (Image courtesy of FootEducation.com)

Thenavicular bone sits along the medial aspect of the foot and articulates withthe talus, the cuneiforms, the cuboid, and the calcaneus. An accessorynavicular is clinically defined as an enlargement of the navicular bone alongits plantar medial surface. This enlargement can be a separate piece of boneconnected to the native navicular body by fibrous or cartilaginous tissue, orit can simply be an enlargement of the native bone beyond its normal size (asthe “extra” part of the navicular can be completely ossified to the truenavicular.)

Patientswith a symptomatic accessory navicular often present with pain and tenderness overthe medial palpable bony prominence. They may also have a flat foot, however nocause and effect relationship between an accessory navicular and a flat foothas been proven. Often the pain is aggravated by tight shoes that press againstthe medial prominence.

Plainradiographs are useful in diagnosing an accessory navicular as they can oftenbe seen on standing AP and lateral views. A lateral oblique x-ray of the footmay also be useful to visualize an accessory navicular (Figure 7).


Thisis the most common accessory tarsal bone seen in the foot with a prevalence ofapproximately 10%. When present, accessory navicular bones are often bilateral.

Apain and tenderness at the navicular insertion may be from tendinitis of thetibialis posterior tendon (with or without an accessory navicular). A bipartitenavicular can also be seen as a separate osseous navicular structure; it isdistinguished from an accessory navicular by the dorsal displacement of theseparate fragment and maintained articulation with the talus. Less commonly afracture or stress fracture of the navicular may be on the differential. Anavulsion fracture of the accessory navicular can also occur with an eversionmechanism; the clinical exam and imaging should be scrutinized for acutechanges in the cases of trauma with focal findings. Plantar fasciitis can alsopresent with pain along the medial foot.

Ifthe patient has a rigid flatfoot consider alternative diagnoses such as thepresence of a concomitant tarsal coalition or underlying inflammatoryarthropathy.

Patientswho present with a painful accessory navicular are first treated with non-operativemeasures. First line measures include activity modification and shoe wearmodification. If there is a planovalgus foot deformity concomitantly, a valguscorrecting orthotic may help relieve pressure over the area. If this fails torelieve symptoms, rigid immobilization in a short leg cast can be done for aperiod of 4-6 weeks followed by gradual return to activities.

Ifextensive non-operative measures fail to provide long-term relief, surgicalexcision may be considered. Surgical options consist of removal of any ossiclethat may be present along with the bony prominence of the main body of thenavicular bone. The ossicle can sometimes exist within the substance of theposterior tibialis tendon, which must be taken into consideration whenperforming surgical excision. Others have described removal of the ossicle andadvancement or re-routing of the tibialis posterior. While good results arereported with either approach, it should be noted that this is based on small,low level of evidence studies.

PlanovalgusFoot Deformity

Pesplanovalgus is defined as excessive valgus alignment of the heel (hindfoot)with loss or flattening of the medial longitudinal arch of the foot. It iscommonly known as “flatfoot,” (see Figure 8). In this condition, the forefootis abducted outward but often rotated inward, or supinated, in relation to thehindfoot. A planovalgus foot is also called a flatfoot. This may be aphysiologic variant or due to underlying pathology. The focus here will be onflexible pes planovalgus flatfoot.

Figure 8: Clinical photo of flexible flatfoot. (Image courtesy of FootEducation.com)

Aflat foot is a combination of foot deformities that includes a valgus hindfootand an abducted and supinated forefoot. In pes planovalgus there is flatteningof the medial longitudinal arch of the foot along with the excessive hindfootvalgus. The normal alignment of the hindfoot can be up to 5 degrees of valgus. Inpes planovalgus the forefoot is abducted and supinated in relation to the hindfoot.Young children develop a medial longitudinal arch over time and this flatteningcan improve.

(Video) Common Pediatric Foot Deformities

Patientswill present with loss of the medial longitudinal arch and a valgus hindfoot. Inorder to assess the degree of forefoot supination, the hindfoot must becorrected to a neutral position. If both deformities can be corrected to aneutral position, the flat foot is said to be flexible.

Anotherway to assess for flexibility is to have the child stand on their toes. If whenstanding on their toes the medial arch re-constitutes and the heel inverts, thedeformity is said to be flexible. A flexible flat foot is caused by an equinuscontracture due to a gastrocnemius muscle contracture and/or a tight Achillestendon. To assess for the degree of gastrocnemius or Achilles tightness, thehindfoot must again be corrected to a neutral position. One may then perform aSilfverskiöld test to further assess where the tightness is originating. This testis performed by comparing the amount of maximal ankle dorsiflexion with theknee flexed versus extended. If more ankle dorsiflexion was achieved with theknee flexed than with the knee extended, the primary tightness is from the gastrocnemiusmuscle. If dorsiflexion is limited in both knee extension and knee flexion, thecontracture is of the Achilles tendon itself also called the heel cord. This isimportant when considering surgical intervention.

Imagingstudies are usually not needed for flexible flat foot diagnosis, but may berequired if other etiology is suspected. All x-rays should be obtained whilethe patient is bearing weight. The lateral radiograph can be helpful toquantify the deformity using the talus-first metatarsal angle, also known asthe Meary angle (Figure 9). This is measured by placing a line along thelongitudinal axis of the talus and a second line along the longitudinal axis ofthe first metatarsal. The angle formed by the intersection of these two linesshould be near zero in a normal foot.

Figure 9: Pes Planus on lateral standing xray. Meary’s angle is the angle between a line drawn from the centers of longitudinal axes of the talus and the first metatarsal. In the normal foot, Meary's angle is roughly zero: the two lines are parallel.

Theincidence of flexible flat foot is not known, likely due to the fact that thisis considered within natural physiologic variation. It is common in infants andchildren, while up to 20% of adults have a flexible flatfoot. A physiologicflat arch in a young child that is asymptomatic is likely to improve over timewithout intervention.

Underlyingdisorders that can be associated with a flatfoot include: accessory navicular,ligamentous laxity, neurologic or neuromuscular disorders, and obesity.

Ifa patient presents with a rigid flatfoot deformity the possibility of otherdiagnoses must be considered. These can include, but are not limited to: tarsalcoalition, spastic peroneal flatfoot, inflammatory arthropathy, previous trauma,and congenital vertical talus.

Ifthe patient has a rigid flatfoot you should consider alternate diagnoses suchas a tarsal coalition or underlying inflammatory arthropathy.

Flexibleflat foot may also be thought of as a normal anatomic variation and not adisabling deformity. No treatment is needed for asymptomatic flat feet. If childrenor adolescents are symptomatic, over the counter shoe inserts may help relievesymptoms but will not change the shape of the foot. If the child has a tight Achillesor gastroc-soleus-complex, an Achilles stretching program should be initiated.Surgery is rarely indicated in the treatment of flexible flat foot. When performedit may consist of tightening of the soft tissues medially, tendon lengtheningand transfer, and osteotomies to lengthen the lateral column of the foot.

Inthe setting of primary tightness of the gastrocnemius muscle (as found with apositive Silfverskiöld test), a gastrocnemius recession can be performed toselectively lengthen the gastrocnemius muscle. If the Silfverskiöld test isnegative, but passive dorsiflexion is limited, a tendoachilles lengthening isperformed.

CavusFoot Deformity

Acavus foot is one with a high arch in the midfoot due to pronation of theforefoot on the hindfoot. The hindfoot can be in neutral (isolated cavus) butis often in varus (cavovarus). In most cases, a cavovarus foot is secondary toan underlying neurologic disorder which causes a muscle imbalance. Cavus mayalso be a result ofresidual clubfoot deformity. Cavus may rarely result from trauma such as compartmentsyndrome, sciatic nerve injury, or tendon lacerations.

Acavus foot is the result of muscle imbalance with weak intrinsicmuscles thatbecome contracted. Cavovarus foot deformity is combination of the high archwith forefoot pronation and inversion or varus of the hindfoot. The midfoot maybe adducted or neutral. The ankle may be plantarflexed, neutral, or indorsiflexion. There is often concomitant external tibial torsion. Another typeof cavus foot deformity is calcaneovarus where the entire arch is elevated offthe ground from medial to lateral.

Often,patients will present with a complaint of recurrent ankle sprains or ankleinstability. This instability can be the result of actual muscle weakness, lossof sensation over the foot, or from the deformity itself. It is also common fora callus to form along the lateral base of the fifth metatarsal due to thepatient walking on the lateral border of their foot. It is vital to obtain adetailed neurologic exam as well as to obtain a detailed family history inthese patients to evaluate for an underlying cause. Patients may haveasymmetric muscle bulk or a leg length discrepancy. An examination of the spineis important to look for signs of spinal dysraphism.

Toevaluate for the deformity itself, providers can look for what is called the“Peek-a-Boo” sign. This sign occurs when the medial aspect of the heel can beseen while looking from straight on, as the patient is standing (Figure 10).

Figure 10: A clinical photo of the “Peek-a-boo sign." (Image courtesy of FootEducation.com)

Anassessment of both the hindfoot and the forefoot are important to ascertain theflexibility of each of these segments. The Coleman block test can be used toassess the flexibility of the hindfoot by placing a block under the lateralfoot and metatarsals and allowing the medial forefoot to hang free (see Figure11). If the varus position of the hindfoot corrects it is flexible.

Figure 11: The Coleman block test is used to determine if the hindfoot varus deformity is flexible or fixed/rigid. As shown in image 1a, there is hindfoot varus of the right foot. By having the patient stand on the block such that only the lateral aspect of the foot is supported, 1b, hindfoot corrects to neutral, indicating a flexible deformity. The Coleman block test counteracts the plantar flexed first ray allowing the hindfoot to return to a normal alignment - if the hindfoot is still flexible. (Image courtesy of http://www.labome.org/research/The-dynamic-coleman-block-test-a-novel-examination-technique-for-cavo-varus-feet.html)

(Video) Pediatric Foot - Dr. Sabatini

Uponpresentation, plain radiographs are often obtained. A cavus foot will have anincreased calcaneal pitch (>30 degrees), which is determined by the anglebetween the long axis of the calcaneus and a line parallel to the bottom of thefoot. The Meary angle can also indicate a cavus foot if it angles upward with amagnitude of more than 4 degrees (Figure 12).

Figure 12: Pes Cavus on lateral standing x-ray. Meary’s angle (red) and the calcaneal pitch angle, between the long axis of the calcaneus and the bottom of the foot (green), are shown.

An AP Pelvis radiograph should be obtained to fully evaluate the patient with a cavovarus foot, as one cause of the foot deformity, Charcot-Marie-Tooth, is associated with hip dysplasia. Likewise, spinal radiographs should be obtained to exclude scoliosis in patients with a cavovarus foot.

Cavus foot deformities are associated with neuromuscular disorders. The most common neuromuscular disorder causing a cavus foot deformity is Charcot-Marie-Tooth (CMT) disease. CMT is the most common hereditary motor sensory neuropathy. In CMT, the peroneus longus is the last muscle to atrophy and weaken. Unopposed pull of this muscle (ie, while it is relatively strong and other muscles are weak) will cause hindfoot varus and a cavus deformity to the arch. Rarely no underlying etiology can be identified for a cavus foot.

Thereare several causes of cavus foot deformities with some being more common inbilateral deformities. These can include: CMT disease, Friedrich’s ataxia,spinal muscular atrophy (SMA), myelomeningocele, cerebral palsy (CP), andrecurrent clubfoot. A unilateral cavus foot deformity can have the same causes,but should also consider previous trauma, peripheral nerve injury,poliomyelitis, tendon injury, or prior compartment syndrome.

Adetailed evaluation of strength, sensation, reflexes, and vascularity is required.A new or progressive cavovarus foot deformity should raise concern forunderlying neurologic abnormalities and a referral to neurology and advancedimaging of the spine and brain with MRI is indicated. Acavovarus foot should be considered a manifestation of an underlyingneuromuscular disorder until proven otherwise.

Thefirst step in treatment of a cavus foot deformity is to diagnose and treat anypotential underlying cause (i.e. neuromuscular disorder). Non-operativetreatment options for a cavus foot include arch supports and shoe modifications.However, many severe cavus foot deformities in children do require surgery inthe long term as the deformity is often progressive.

Indicationsfor surgery are progressive deformity, pain, pressure injuries, and gaitinstability. When deciding on surgical management, it is important tounderstand how rigid or flexible the deformity is and where. The hindfoot andforefoot are the important considerations and one may be flexible while theother stiff. This can be accomplished by using the Coleman block test asdescribed. This test helps the examiner determine whether the deformity isforefoot or hindfoot driven, and what aspects of the foot need to be addressedduring surgical reconstruction. There is not one surgical procedure for themanagement of a cavovarus foot, but rather there are many procedures that maybe performed to address whatever aspects of the patient’s foot are contributingto the deformity.

Surgical treatment can be divided into these broad categories: soft tissue, osteotomy, arthrodesis. Contractures should be released and the soft tissues should be rebalanced in all cases. In flexible feet, this may be all the surgery that is required. In more advanced cases with stiffness or rigidity, osteotomies to correct the adaptive boney changes are required. Finally, in cases of advanced rigid deformities, older patients may consider fusion as a last resort

Thebiggest risk factor for a cavus foot deformity is an underlying neuromusculardisorder.

Miscellany

Metatarsusadductus has also been called “bean foot” due to the shape.

Thenavicular is known as the scaphoid of the foot. Both names refer to the “boatshape” of the bone (sharing roots with the word “navy” and “skiff”).

KeyTerms

Cavus,cavovarus, metatarsus adductus, flatfoot, hindfoot, forefoot, Silfverskiöldtest, tarsal coalition, rigid flatfoot, subtalar joint, calcaneonavicular joint,navicular, tarsal bones, tibialis posterior

Skills

Recognizethe normal shape of the foot. Distinguish relationships between the forefoot,midfoot, hindfoot. Distinguish a flexible from a rigid flat foot. Be able toidentify a cavus foot deformity. Understanding the “peek-a-boo” sign. Understandhow to perform and interpret the Coleman block test. Recognize that there maybe many normal anatomical variants in the foot with bony structure.

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FAQs

Pediatric Foot Deformities? ›

Pediatric foot deformity is a term that includes a range of conditions that may affect the bones, tendons, and muscles of the foot. Among those most frequently treated at HSS are cavus foot, tarsal coalition, clubfoot, accessory navicular, and juvenile bunion.

What is the most common pediatric foot deformity? ›

Metatarsus adductus is the most common congenital foot deformity occurring in approximately 1 of every 1000 live births, with equal frequency in males and females. Metatarsus adductus is bilateral in approximately 50% of cases. Metatarsus adductus is defined on clinical examination by the heel bisector line.

What is the most common foot deformity? ›

Two of the most common foot and ankle deformities are bunions and hammertoes. Do you know what they are and what steps to take to treat them? A bunion occurs when bones shift out of place in the foot. Bunions most commonly develop at the joint where the big toe joins the rest of the foot.

What causes foot deformation? ›

Placing a substantial amount of strain on the foot or regularly wearing tight and improper footwear can all lead to the development of a foot deformity. Other contributing factors for foot deformities include injuries, inflammation, and obesity, as well as diseases such as osteoarthritis and/or rheumatoid arthritis.

What is Calcaneovalgus foot deformity? ›

Calcaneovalgus foot is one of the most common deformities of the foot seen in newborns. Babies with this condition are born with their foot and ankle excessively bent up, where the toes are usually touching the shin. This deformity may also present in older children, but is usually a manifestation of another condition.

What is Sever's disease? ›

Sever's disease is a painful condition of the heel that occurs in growing children. It happens when the tendon that attaches to the back of the heel (the Achilles tendon) pulls on the growth plate (the apophysis) of the bone of the heel (the calcaneus).

What are types of foot deformities? ›

Common Types of Foot Deformities
  • Bunions (Hallux Valgus) Bunions can be a very painful foot deformity. ...
  • Hammertoe, Claw Toe, and Mallet Toe. ...
  • Flatfoot (Pes Planus) ...
  • High Arches (Pes Cavus)
Apr 24, 2020

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