Pediatric Flatfoot Deformity Case Study Evaluation …...Pediatric Flatfoot Deformity Case Study...
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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. 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. 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. 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. 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). 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). 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). 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. REFERENCES: 1. Yeagerman SE, Cross MB, Positano R, Doyle SM. Evaluation and treatment of symptomatic pes planus. Cur Opin Pediatr 23: 60-67, 2011. 2. Harris EJ, Vanore JV, Thomas JL, Kravitz SR, Mendelson SA, Mendicino RW, Silvani SH, Gassen SC. Diagnosis and treatment of pediatric flatfoot. J Foot Ankle Surg 43: 341-370, 2004. 3. Pfeiffer M, Kotz R, Ledl T, Hauser G, Sluga M. Prevalence of flatfoot in preschool-aged children. J Pediatr 118: 634-639, 2006. 4. Evans AM, Rome K. A Cochrane review of the evidence for non-surgical interventions for flexible pediatric flatfeet. Eur J Phys Rehabil Med 47: 69-89, 2011. 5. Sullivan JA. Pediatric flatfoot: Evaluation and Management. J Amer Acad Ortho Surg 7: 44-53, 1999. 6. Mckie J, Ramdomisli T. Congenital vertical talus: A review. Clin Podiatr Med Surg 27: 145-156, 2010. 7. Rodriguez N, Choung DJ, Dobbs MB. Rigid pediatric pes planovalgus: conservative and surgical treatment options. Clin Podiatr Med Surg 27: 79-92, 2010. 8. Evans AM. The flatfooted child- To treat or not to treat. JAPMA 98: 386-393, 2008. 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).
Transcript of Pediatric Flatfoot Deformity Case Study Evaluation …...Pediatric Flatfoot Deformity Case Study...
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. 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.
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.
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.
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).
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).
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).
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.
REFERENCES: 1. Yeagerman SE, Cross MB, Positano R, Doyle SM. Evaluation and treatment of symptomatic pes planus. Cur Opin Pediatr 23: 60-67, 2011. 2. Harris EJ, Vanore JV, Thomas JL, Kravitz SR, Mendelson SA, Mendicino RW, Silvani SH, Gassen SC. Diagnosis and treatment of pediatric flatfoot. J Foot Ankle Surg 43: 341-370, 2004. 3. Pfeiffer M, Kotz R, Ledl T, Hauser G, Sluga M. Prevalence of flatfoot in preschool-aged children. J Pediatr 118: 634-639, 2006. 4. Evans AM, Rome K. A Cochrane review of the evidence for non-surgical interventions for flexible pediatric flatfeet. Eur J Phys Rehabil Med 47: 69-89, 2011. 5. Sullivan JA. Pediatric flatfoot: Evaluation and Management. J Amer Acad Ortho Surg 7: 44-53, 1999. 6. Mckie J, Ramdomisli T. Congenital vertical talus: A review. Clin Podiatr Med Surg 27: 145-156, 2010. 7. Rodriguez N, Choung DJ, Dobbs MB. Rigid pediatric pes planovalgus: conservative and surgical treatment options. Clin Podiatr Med Surg 27: 79-92, 2010. 8. Evans AM. The flatfooted child- To treat or not to treat. JAPMA 98: 386-393, 2008.
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).
