harris et al. (2004) - diagnosis and treatment of pediatric flatfoot
TRANSCRIPT
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 1/33
CLINICAL PRACTICE GUIDELINE
Diagnosis and Treatmentof Pediatric Flatfoot
Clinical Practice Guideline Pediatric Flatfoot Panel: Edwin J. Harris, DPM,1
John V. Vanore, DPM,2 James L. Thomas, DPM,3 Steven R. Kravitz, DPM,4
Stephen A. Mendelson, MD,5 Robert W. Mendicino, DPM,6
Stephen H. Silvani, DPM,7 and Susan Couture Gassen8
This clinical practice guideline (CPG) is based on the con-
sensus of current clinical practice and review of the clinical
literature. The guideline was developed by the Clinical Practice
Guideline Pediatric Flatfoot Panel of the American College of
Foot and Ankle Surgeons. The guideline and references anno-
tate each node of the corresponding pathways.
Introduction to Pediatric Flatfoot ( Pathway 1 )
Foot and ankle specialists acknowledge that flatfoot de-
formity is a frequently encountered pathology in the pedi-
atric population. Flattening of the medial arch is a universal
finding in flatfoot and it is common in both pediatric andadult populations. Pediatric flatfoot comprises a group of
conditions occurring in infants, children, and adolescents
(1) that are distinguished by anatomy and etiologic factors
(2, 3– 8).
Flatfoot may exist as an isolated pathology or as part of
a larger clinical entity (4). These entities include generalized
ligamentous laxity, neurologic and muscular abnormalities,
genetic conditions and syndromes, and collagen disorders.
Pediatric flatfoot can be divided into flexible and rigid
categories. Flexible flatfoot is characterized by a normal
arch during nonweightbearing and a flattening of the arch on
stance (Fig 1). Flexible flatfoot may be asymptomatic or
symptomatic. Rigid flatfoot is characterized by a stiff, flat-
tened arch on and off weightbearing. Most rigid flatfeet areassociated with underlying pathology that requires special
consideration.
Skewfoot is an uncommon disorder characterized by se-
vere pronation of the rearfoot and an adductovarus forefoot.
Skewfoot has characteristics of flatfoot and adductovarus
deformity (8).
Significant History ( Pathway 1, Node 1)
Pediatricians and parents often are the first to recognize
foot and ankle pathology in infants and children, but prob-
lems may go unrecognized for a long period of time. The
age of onset is important for diagnostic and therapeutic
decision making. Additional considerations include family
history, associated medical conditions, presence or absence
of symptoms, trauma history, activity level, previous treat-
ment, and a thorough review of systems.
Documented failure to improve, or a clinical worsening,
is contrary to the normal course and suggests that the
problem is more likely to persist with the possibility of
pathologic sequel. A family history of flatfoot suggests that
there may be similar issues in the child. Obesity, neuromus-
cular disorders, and structural abnormalities above the level
of the ankle (eg, ankle valgus, tibia varum, genu valgum,tibial torsion, femoral anteversion, limb-length discrepancy)
can influence both the natural history and the severity of
pediatric flatfoot.
Flatfoot can be associated with a number of subjective
symptoms that may include pain in the foot, leg, and knee, and
postural symptoms. A history of trauma—acute or repetitive—
may cause or unmask the foot deformity. Flatfoot deformity
may result in decreased endurance and voluntary withdrawal
1Chair, Pediatric Flatfoot Panel, Westchester, IL; 2Chair, Clinical Prac-tice Guideline Core Committee, Gadsden, AL; 3Board Liaison, Birming-ham, AL; 4Philadelphia, PA; 5Pittsburgh, PA; 6Pittsburgh, PA; 7WalnutCreek, CA; 8Chicago, IL. Address correspondence to: John V. Vanore,DPM, Gadsden Foot Clinic, 306 South 4th St, Gadsden, AL 35901. E-mail: [email protected]
Copyright © 2004 by the American College of Foot and Ankle Surgeons1067-2516/04/4306-0002$30.00/0doi:10.1053/j.jfas.2004.09.013
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 341
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 2/33
from physical activities. Previous treatment may have modified
the clinical presentation (4). A comprehensive history and
review of systems may show previously unsuspected medical
conditions (4). For example, a history may disclose clumsiness
and frequent falling. Difficulty climbing and difficulty arising
from the floor in association with flatfoot may indicate Becker
or Duchenne muscular dystrophy.
Significant Findings ( Pathway 1, Node 2)
The appearance of the foot during weightbearing and
nonweightbearing suggests the presence and type of flatfoot
deformity (Fig 1). Physical findings may include low arch
structure, rearfoot eversion, medial talar head prominence,
altered walking, and the presence of calluses.
Evaluation of flatfoot requires assessment of ankle dor-
siflexion and plantarflexion (with knee extended and flexed)
and rearfoot, midfoot, and forefoot ranges of motion. The
forefoot-to-rearfoot relationship is also assessed. Tender-
ness may be present in pediatric flatfoot, occurring along the
medial column and at the metatarsal heads, plantar fascia,
sinus tarsi, and ankle.
Gait observation should be conducted when the child is
barefoot and is wearing shoes. Gait should be assessed
for prominence of the medial border of the midfoot, the
foot progression angle, calcaneal eversion (pronation and
resupination during stance phase), the heel-to-toe con-
tact, position of the knee, and presence of limp.Diagnostic observations and maneuvers include inver-
sion of the heel on toe rise, recreation of the medial arch
with dorsiflexion of the hallux, and the “too many toes
sign.” Other physical findings include obesity, tibia va-
rum, genu valgum, tibial torsion, femoral torsion, disor-
ders of muscle tone, and ligamentous laxity that can
modify both the natural history and the severity of flat-
foot (9).
PATHWAY 1
342 THE JOURNAL OF FOOT & ANKLE SURGERY
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 3/33
FIGURE 1 Clinical examination of the foot begins with nonweightbearing inspection. ( A ) The pediatric flexible flatfoot shows preservation
of the medial arch off weightbearing, whereas ( B ) the arch depresses or flattens with weightbearing. ( C ) The relaxed calcaneal stance position
is viewed from the posterior. The heels may evert and the tendo-Achilles bows laterally (positive Helbing sign). ( D ) Ankle dorsiflexion is
assessed during the examination, because equinus is a frequent component or etiologic factor of flatfoot pathologies. ( E ) The everted or
valgus heel in stance changes to ( F ) a varus position with the clinical maneuver of heel rise to the toes, showing the flexible nature and the
reducibility of the deformity.
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 343
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 4/33
Diagnostic Studies ( Pathway 1, Node 3)
Imaging options may include radiographs (Fig 2)
(weightbearing), computed tomography (CT), magnetic res-
onance imaging (MRI), and bone scans. Serologic studies
may be warranted to differentiate mechanical or overuse
symptoms from arthralgia, arthritis, and other childhood
inflammatory diseases.
Diagnosis ( Pathway 1, Node 4)
Information from the initial evaluation and diagnostic
tests is correlated into a diagnosis. The differential diagnosis
of the pediatric flatfoot includes the following: flexible
flatfoot (Pathway 2); rigid flatfoot: congenital vertical talus
(CVT) (Pathway 3); tarsal coalition (Pathway 4); peroneal
spastic flatfoot without coalition (Pathway 5); iatrogenic
and posttraumatic deformity (Pathway 6); skewfoot (Path-
way 7); and flatfoot caused by other, less frequent causes
(Pathway 8) (2, 4, 8, 10). Note that 4 of these conditions—
vertical talus, tarsal coalition, peroneal spastic flatfoot with-
out coalition, and iatrogenic/posttraumatic deformity—are
types of rigid flatfoot.
Flexible Flatfoot ( Pathway 2 )
Asymptomatic Flexible Flatfoot ( Pathway 2 )
The asymptomatic flexible flatfoot may be physiologic or
nonphysiologic (Nodes 5 and 6) (11). Most flexible flatfeet
are physiologic, asymptomatic, and require no treatment (7,
12, 13). Physiologic flexible flatfoot follows a natural his-
tory of improvement over time (Fig 3). Periodic observationmay be indicated to monitor for signs of progression (Node
5). Treatment generally is not indicated (14).
Nonphysiologic flexible flatfoot is characterized by pro-
gression over time. The degree of deformity is more severe
in nonphysiologic than in physiologic flexible flatfoot. The
amount of heel eversion is excessive; the talonavicular joint
is unstable. Additional findings include tight heel cords and
gait disturbance. Periodic observation is indicated in non-
physiologic flexible flatfoot (Node 7). Patients with tight
heel cords may benefit from stretching (Node 8) (13). Or-
thoses may also be indicated.
Children with asymptomatic flexible flatfoot should bemonitored clinically for onset of symptoms and signs of
progression (Node 7). Continued progression requires reas-
sessment to identify other underlying disease.
Symptomatic Flexible Flatfoot ( Pathway 2, Node 6)
Unlike physiologic and asymptomatic nonphysiologic
flexible flatfoot, symptomatic forms of flexible flatfoot
produce subjective complaints, alter function, and produce
significant objective findings. These include pain along the
medial side of the foot; pain in the sinus tarsi, leg, and knee;
decreased endurance; gait disturbances; prominent medial talar
head; everted heels; and heel cord tightness.
Initial treatment (Node 8) includes activity modifica-
FIGURE 2 Radiographic examination includes weightbearing ( A )
AP and ( B ) lateral radiogr aphs taken in the angle and base of gait
for further evaluation and documentation of the degree of
deformity. Radiographic flatfoot parameters focus on the rela-
tionship of the talus and calcaneus. The midtalar line (solid black
line), talocalcaneal angle (TC) and calcaneal inclination angle
provide information on the sagittal plane position of these bones
on lateral view and transverse plane position on the AP view. In
flatfoot, the talocalcaneal angle increases in size both on the AP
and lateral radiographs. The talus plantarflexes in flatfoot
deformity on the lateral radiograph. The normal midtalar line
should pass through the first metatarsal. On the weightbearing
AP radiogr aph, the talar head is no longer covered by its articu-
lation with the navicular. This results in a wide AP talocalcaneal
angle (Kite angle). Calcaneal inclination decreases in flatfoot.
(Further discussion can be found in the American College of Foot
and Ankle Surgeons Clinical Practice Guideline on Adult Flatfoot.)
344 THE JOURNAL OF FOOT & ANKLE SURGERY
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 5/33
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 6/33
tions and orthoses. Stretching exercises for equinus
deformity can be performed under physician or physical
therapist supervision. Nonsteroidal antiinflammatory
medications may be indicated in more severe cases. Co-
morbidities, such as obesity, ligamentous laxity, hypoto-
nia, and proximal limb problems, must be identified and
managed, if possible.
If there is a positive clinical response and symptoms
are resolved, observation and orthoses (when appropri-
ate) are instituted. If clinical response is not satisfactory,
reassessment and additional work-ups are indicated.
When all nonsurgical treatment options have been ex-
hausted, surgical intervention can be considered (13,
15–21).
Surgical Intervention ( Pathway 2, Node 10)
Surgical management of the flexible flatfoot can be
grouped into 3 types: reconstructive procedures, arthrodesis,
and arthroereisis.
Soft tissue reconstruction of the flexible flatfoot is rarely
successful as an isolated procedure. Bony procedures in-
clude rearfoot, midfoot, and forefoot osteotomies. Depend-
ing on the plane of dominance of the deformity, lateral
column lengthening (Fig 4) and/or medial displacement
osteotomy of the posterior calcaneus may be used. A heel
cord lengthening and medial plication are often included asa part of these procedures. Although excellent results from
surgical treatment of flatfoot have been described, questions
remain regarding successful long-term correction (14).
Arthroereisis involves insertion of a spacer into the sinus
tarsi for the purpose of restricting subtalar joint pronation
(22–25) (Fig 5). Proponents of this procedure argue that it is
a minimally invasive technique that does not distort the
normal anatomy of the foot (24, 26–28). Others have ex-
pressed concern about placing a permanent foreign body
into a mobile segment of a child’s foot (29, 30). The
indication for this procedure remains controversial in the
surgical community (25, 26, 28, 31–38).
Arthrodesis of the rearfoot has also been described fortreatment of symptomatic flexible flatfoot. Subtalar arthro-
desis is typically performed as the primary procedure. Triple
arthrodesis is reserved as a salvage procedure for previously
failed surgical treatment. Although arthrodesis provides a
FIGURE 3 Radiographic examination of foot deformities is essen-
tial for both diagnostic evaluation and documentation. Radiographs
of pediatric deformities allow comparison of progression with time
and assessment of therapeutic results. This case is a neurologically
healthy 4-year-old girl who was treated for flexible flatfoot with
nonpronating orthotics. ( A
) The initial AP and lateral radiographsshow medial talar head uncovering and a wide talocalcaneal angle.
( B ) The initial lateral radiograph shows decreased calcaneal inclina-
tion angle and increased talar declination angle. ( C ) Three years
later, there is improvement in the radiographic parameters with
increased talar head coverage on the AP view. ( D ) The lateral
radiograph shows improvement of arch height, although the calca-
neal inclination and talar declination are similar to the pretreatment
studies. Although it is tempting to credit orthotic therapy for the
observed improvement, it is equally possible that these changes are
the result of the natural history of spontaneous improvement.
346 THE JOURNAL OF FOOT & ANKLE SURGERY
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 7/33
FIGURE 4
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 347
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 8/33
stable foot and durable correction, eventual transfer of en-
ergy to the nonfused joints adjacent to the fusion is of
concern (39, 40).
If surgical intervention is successful in producing a func-
tional painless result, the child should be further treated by
periodic observation and appropriate orthoses. If surgery
fails, salvage through appropriate intraarticular or extraar-
ticular arthrodesis is appropriate.
Rigid Flatfoot (Pathway 3 to 6)
Rigid flatfoot is characterized by a lowered arch on both
weightbearing and nonweightbearing and by a decrease or
absence of motion of the rearfoot and midfoot. Rigid flatfoot
can be symptomatic or asymptomatic. Most cases are asso-
ciated with underlying primary pathology that can be diag-
nosed by clinical and imaging examinations.
The differential diagnosis of rigid pediatric flatfoot in-
cludes CVT (Pathway 3), tarsal coalition (Pathway 4), per-
oneal spastic flatfoot without coalition (Pathway 5), andiatrogenic or traumatic joint pathology (Pathway 6).
Congenital Vertical Talus ( Pathway 3 )
CVT deformity, also known as congenital convex pes
valgus, is characterized by severe equinus of the rearfoot
and by a rigid rocker-bottom appearance. There are 2
classes of this deformity: teratologic and idiopathic.
Teratologic CVT indicates the presence of underlying
comorbid conditions. These include genetic syndromes, spi-
nal dysraphisms (41–43), prune belly syndrome (44), de
Barsy syndrome (45), distal arthrogryposis (46), arthrogry-posis multiplex congenita (47), congenital metacarpotalar
syndrome (48), Rasmussen syndrome (49–51), and a host of
chromosomal abnormalities (52).
Idiopathic CVT lacks specific etiologic factors (52–61).
CVT has been associated with a tarsal coalition (62). Ge-
netic issues in idiopathic CVT have not been resolved
because of inconclusive data. Results of some studies sug-
gest a hereditary component (58, 63, 64), whereas others fail
to show patterns of inheritance (65, 66).
Significant History ( Pathway 3, Node 1)
CVT deformity should be diagnosed at birth but it is
sometimes confused with calcaneovalgus deformity or
physiologic flatfoot. Symptoms begin at walking age, with
difficulty bearing weight and wearing shoes. There may be
a history of previous unsuccessful treatment.
Significant Findings ( Pathway 3, Node 2)
CVT is characterized by a rigid rocker-bottom appear-
ance to the foot (Fig 6). Pathology findings include dorsal
dislocation of the talonavicular joint, ankle equinus, con-
tracture of the tendo-Achilles, long-toe flexors, posterior
ankle capsule, peroneal tendons, and the anterior compart-
ment tendons (59, 67). The tibionavicular ligament is con-
tracted; the calcaneonavicular (spring) ligament is elon-
gated.
The forefoot is most frequently abducted, but may occa-
sionally be adducted (68). The calcaneocuboid articulationoften remodels so that the entire plantar aspect of the foot is
convex (68). Tibialis posterior and the peroneals may be
displaced, the talar head becomes misshapen, and the de-
formity is extremely rigid. It is most likely resistant to
closed reduction (53, 66, 69–71).
Diagnostic Imaging ( Pathway 3, Node 3)
Plain radiographs are most often diagnostic (61). Lat-
eral weightbearing radiographs show parallelism between
the tibia and the talus. The calcaneus is in equinus
(Fig 6).If the navicular has not ossified, a plantarflexion stress
lateral radiograph will determine the reducibility of the
forefoot on the talus. The longitudinal axis of the first
metatarsal will not align with the bisection of the talus. If
the navicular has already ossified, its malposition in refer-
ence to the talus is visualized. It is not reduced on plantar-
flexion.
On the anteroposterior (AP) projection, the talocalcaneal
(Kite) angle will be very wide. The navicular (if visualized)
FIGURE 4 Selection of apropriate surgical treatment is based on the clinical and radiographic evaluation. Planal dominance is an important
factor. A flatfoot deformity will usually show significant deformity in one or more of the cardinal body planes. A 12-year-old boy had a 2-year
history of progressing pain in both feet after walking long distances and after athletic activities. ( A ) The medial border of the foot is
characterized by talar-head bulging and by the loss of medial arch height. ( B ) The lateral border is abducted and the calcaneus is everted.
( C ) The midtarsal joint complex is pronated on the AP radiograph, and the talar head is uncovered. ( D ) The lateral radiograph shows abnormal
calcaneal inclination, increased talocalcaneal angle, and sagittal collapse of the medial column. The patient underwent an Evans opening
calcaneal osteotomy with insertion of banked bone graft, a plantarflexing first metatarsal osteotomy, and a percutaneous tendo-Achilles
lengthening. ( E and F ) Marked improvement in the talocalcaneal angle, and improved calcaneal inclination and height of the medial arch, are
seen on the AP and lateral postoperative radiographs.
348 THE JOURNAL OF FOOT & ANKLE SURGERY
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 9/33
FIGURE 5 Arthroereisis is an evolving procedure for the
treatment of flexible flatfoot. Both polymer and metallic
implants are commercially available. ( A ) This weightbearing
preoperative AP radiograph shows a wide talocalcaneal
angle with approximately 50% of the medial talar head
uncovered. The midtarsal joint complex is completelypronated. ( B ) The preoperative lateral radiograph shows a
large lateral talocalcaneal angle, decreased calcaneal incli-
nation angle, anterior alteration of the Cyma line, and mid-
tarsal fault. ( C ) After metallic subtalar arthroereisis, the
postoperative AP shows the talonavicular joint completely
reduced. The AP talocalcaneal (Kite) angle is also reduced
compared with the preoperative study. ( D ) The postopera-
tive lateral shows significant change in the talotibial and
talocalcaneal relationships. The forefoot is supinated.
(Case courtesy of John Grady, DPM, Chicago, IL.)
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 349
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 10/33
PATHWAY 3
350 THE JOURNAL OF FOOT & ANKLE SURGERY
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 11/33
will be displaced laterally and will appear to overlap the
distal aspect of the talar head.
MRI, CT, and ultrasound studies may be useful in imag-
ing the deformity for diagnosis and for surgical planning
(72–75).
Diagnosis ( Pathway 3, Node 4)
Diagnosis of vertical talus is made by the appearance of
a rigid and irreducible foot, with support from imaging
studies. The differential diagnosis must include calcaneo-
valgus deformity, which is flexible, does not have a rocker-
bottom configuration, and does not have a talonavicular
dislocation (76).
Initial Treatment ( Pathway 3, Node 5)
Initial management of CVT consists of manipulation and
serial casting for approximately 6 week s (77). During ma-
nipulation, an attempt is made to pull the navicular distally,downward, and medially to relocate it on the talar head.
If closed reduction occurs (Node 6), the talonavicular
joint can be pinned in percutaneous fashion (Fig 7). At that
point, the equinus may be corrected by casting. If complete
reduction is achieved, an ankle-foot orthosis can be pre-
scribed (Node 7). The patient must be carefully observed
because of an extremely high recurrence rate.
Surgical Intervention ( Pathway 3, Node 8)
Long-term results of closed reduction have been reported
as poor (70). If closed reduction is not successful, opensurgical reduction is necessary (65, 66, 68, 69, 77, 78).
Reduction may be performed in 1 (52, 53, 59, 79, 80) or 2
(68, 81) stages. The benefits and value of the 2 techniques
have been examined by a number of authors (54, 82).
For infants, the Cincinnati incision gives excellent expo-
sure to the rearfoot components of the deformity (61).
However, this incision is not recommended for older chil-
dren because of concerns about skin perfusion after this
approach (83). The goal of surgery is to correct hindfoot
equinus, to restore talonavicular congruity, and to restore
functional anatomy. Recurrence is a common problem and
bracing is recommended (Fig 7).
In older children, the talonavicular joint may be so de-
FIGURE 6 Rigid flatfoot deformities are often congenital. Vertical
talus is 1 pathology that should be diagnosed early in life. ( A ) A child
with CVT (congenital convex pes valgus) is characterized clinically
by a pathologic plantigrade foot with weight borne at the midfoot
and the heel off the ground. ( B ) The lateral radiograph shows the
ankle and calcaneus in equinus position, the talus almost vertical,
and the talonavicular joint dislocated. The navicular is not ossified,
but a line passing through the first metatarsal shaft intersects the
dorsal talar neck instead of the talar head. ( C ) A stress plantarflexion
radiograph is diagnostic and shows that only partial reduction of the
talonavicular dislocation is possible.
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 351
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 12/33
FIGURE 7 Vertical talus is generally irreducible nonsurgically. This 3-year-old neurologically healthy girl was diagnosed at 22 months with
CVT deformity. Nonsurgical reduction was not successful. ( A ) The initial surgical approach is peritalar release and pinning of the talonavicular
joint. ( B and C ) These radiographs show some recurrence of the deformity after peritalar release. Note the deformed navicular and severe talar
declination combined with a rocker-bottom deformity.
352 THE JOURNAL OF FOOT & ANKLE SURGERY
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 13/33
formed that reconstruction is not possible. For these pa-
tients, naviculectomy may be the procedure of choice (53,
84–86). The Green-Grice procedure for extraarticular sta-
bilization may also be used (53, 58, 87–89) (Fig 8). It may
be necessary to consider lateral column lengthening (87),
osteotomy of the calcaneus, and subtalar arthrodesis to
maintain the corrected position. Talectomy may also be
indicated in selected cases (68). Tendon transfer for rebal-ancing is frequently added in the surgical treatment plan.
Continued observation and appropriate orthosis therapy fol-
lows.
Tarsal Coalition ( Pathway 4 )
Tarsal coalition is a congenital union between 2 or more
tarsal bones that may be an osseous, cartilaginous, or a
fibrous connection (90, 91). The incidence of tarsal coalition
is 1% to 2% (90–92). Talocalcaneal and calcaneonavicular
bars are the most common. Talocalcaneal coalitions are
most commonly found at the middle facet (90, 91, 93, 94).Talonavicular and calcaneocuboid coalitions also have been
described but are much less common. Autosomal dominant
inheritance has been proposed (90, 95–97).
Significant History ( Pathway 4, Node 1)
Tarsal coalitions may be asymptomatic (91). The child
and parents may become aware of stiffness in the foot and
ankle, altered foot shape, muscle spasm, and protective gait
abnormalities. Symptoms of tarsal coalitions most com-
monly present in preadolescents or adolescents who sud-
denly gain weight and who take on physical activities, suchas sports and forms of manual labor. Onset of symptoms
may be insidious, precipitated by minor trauma or change in
activity (98, 99).
Significant Findings ( Pathway 4, Node 2)
Most symptomatic coalitions present with local tender-
ness around the lateral ankle, sinus tarsi, subtalar joint, or
the coalition site. There is decreased or absent rearfoot
range of motion with or without muscle spasm and some
degree of rigid flatfoot.
FIGURE 8 Recurrence of vertical talus deformity is not uncommon
and may require further treatment with bracing or additional surgery.
( A ) This radiograph shows recurrent deformity in a young girl with
myelomeningocele. Equinus of the talocalcaneal complex, rocker-
bottom deformity, and talonavicular subluxation are present. ( B ) The
patient was treated with a Green-Grice extraarticular subtalar arth-
rodesis. ( C ) Excellent reduction of deformity is seen immediately
postoperative and is maintained on the follow-up radiograph. (Case
courtesy of Loyola University Department of Orthopaedics and Re-
habilitation Pathology Collection, Maywood, IL.)
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 353
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 14/33
PATHWAY 4
354 THE JOURNAL OF FOOT & ANKLE SURGERY
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 15/33
FIGURE 9 Tarsal coalitions account for most rigid flatfoot deformities seen at the community level. ( A ) Talonavicular coalition may be seen
as an incidental finding. These feet are usually asymptomatic. Calcaneonavicular bars are common. ( B ) The lateral radiograph shows an
exaggerated projection of the distal calcaneus (anteater sign). ( C ) Lateral oblique projection shows the connection between the calcaneus and
the navicular. ( D and E ) MRI and CT imaging techniques better delineate the pathology. The talocalcaneal coalition may be diagnostically
more difficult. ( F ) The lateral radiograph may show irregularity of the middle facet or complete obliteration of the middle facet. ( G ) Special
views, such as the Harris-Beath projection, should show parallel relationship between the middle and posterior facets. ( G ) Shown here is an
oblique and poorly visualized middle facet. ( H ) This is verified with a CT image.
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 355
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 16/33
Diagnostic Imaging ( Pathway 4, Node 3)
Calcaneonavicular coalitions can be seen on both lateral
and oblique radiographs of the foot as an upward and medial
prolongation of the calcaneus toward the inferolateral na-
vicular (Fig 9). Depending on the degree of ossification of
the bridge, there may be a lucent line separating the 2 bones.
The 45° oblique plain radiographic view is best for detec-tion of the calcaneonavicular coalition.
Middle facet talocalcaneal coalitions are difficult to visu-
alize because of the complexity of the anatomy and because
many are cartilaginous. The lateral radiograph may show
the “C” or halo sign (the C-shaped line formed by the
medial outline of the talar dome and sustentaculam tali,
which is a secondary sign of a coalition) (100). Harris-Beath
projections may be useful, but they may be difficult to
interpret because of problems with underpenetration. If pos-
itive, the articular end plates of the middle facet are irreg-
ular, the facets angulate down and medial, and there may be
partial bridging evident (101). If angulation is more than
20°, coalition is probable (90, 93, 102). Because of thedifficulty of interpretation, CT and MRI studies have largely
replaced Harris-Beath projections (Fig 9).
CT is the diagnostic test of choice because of its ability to
show the osseous structures (103–105). It is particularly
useful for visualizing talocalcaneal coalitions and for eval-
uating multiple coalitions. Coronal images show the loca-
tion and extent of their involvement (106–111, 112).
MRI is particularly useful in evaluating the immature
skeleton and in determining the presence of other causes of
peritalar pain (90, 103). It is helpful in evaluating fibrocar-
tilagenous coalitions and nonossified coalitions in the very
young (90, 113–116).
Bone scans have been used to show increased stresses at
articular surfaces. Bone scans are sensitive but nonspecific
(117–119).
Diagnosis ( Pathway 4, Node 4)
Diagnosis of tarsal coalition is based on pain and loss of
motion and supported by appropriate imaging studies. Co-
alitions are classified by site, type of interposing tissue,
extent of involvement, and secondary degenerative changes
(Table 1).
Initial Treatment ( Pathway 4, Node 5)
The initial treatment for any coalition should be nonsur-
gical (90, 120–122). Patients with mild symptoms may
respond well to footwear modifications, arch supports, or
custom orthoses. Activity modifications, weight reduction,
antiinflammatory medication, and local anesthetic blocks
may also be indicated (90). Cast immobilization for several
weeks may be indicated for patients with more severe
symptoms or with peroneal spasm (97).
Clinical Response ( Pathway 4, Node 6)
After a period of nonsurgical treatment, patients should
be reevaluated. If symptoms have been relieved, the initial
treatment options should be continued (Node 7), with peri-
odic observation of clinical progress (Node 8).
Surgical Intervention ( Pathway 4, Node 9)
Surgical consideration should be given to those who fail
to respond to nonsurgical treatment (6, 101, 122). Surgical
treatment depends on the type of coalition. Resection of the
coalition may be indicated for individuals without signifi-
cant deformity or arthrosis (Fig 10). In some cases, arthro-
desis may be the procedure of choice.
In children with foot deformity, osteotomy should be
performed in conjunction with resection. If significant ar-
thritic changes are found, arthrodesis should be considered.Isolated talocalcaneal arthrodesis is indicated for subtalar
coalitions (96). If peritalar degeneration is evident, triple
arthrodesis may also be indicated (Fig 11) (101, 102,
120, 122).
Observation and supportive orthoses should follow sur-
gery (Node 8). If symptoms recur, the patient may need to
return to nonsurgical options. These measures are not likely
to provide adequate relief of symptoms.
TABLE 1 Classification of tarsal coalitions
Tissue types Anatomic
Extraarticular
Cartilaginous Calcaneonavicular
Fibrous Cuboidonavicular
Osseous Trigonal
Intraarticular
Talocalcaneal
MiddlePosterior
Anterior
Combination
Talonavicular
Calcaneocuboid
Naviculocuneiform
Articular
Juvenile (osseous immaturity) Adult (osseous maturity)
Type I: Extraarticular coalition Type I: Extraarticular coalition
A. No secondary arthritis A. No secondary arthritis
B. Secondary arthritis B. Secondary arthritis
Type II: Intraarticular coalition Type II: Intraarticular coalition
A. No secondary arthritis A. No secondary arthritis
B. Secondary arthritis B. Secondary arthritis
356 THE JOURNAL OF FOOT & ANKLE SURGERY
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 17/33
FIGURE 10 Calcaneonavicular coalitions may be fibrous, cartilaginous, or osseous. Younger patients may benefit by excision of the bar.
( A and B ) Oblique and lateral radiographs demonstrate the bar as well as the pronatory foot deformity. ( C ) Shown is an intraoperative view
of the excised fragment. Excision should restore the mobility of the rearfoot complex. ( D and E ) The postoperative oblique and lateral
radiographs show adequate resection of the extraarticular bar.
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 357
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 18/33
FIGURE 11 Talocalcaneal coalitions limit or prevent normal joint motion. Once they occur, degenerative joint changes are irreversible.
Treatment in the older adolescent or young adult usually requires subtalar or triple arthrodesis. ( A and B ) AP and lateral radiographs show
significant pronatory foot deformity with low calcaneal inclination, increased talar declination, and depression of the medial column. Clinically,
no subtalar motion is present. ( C ) MRI evaluation shows a middle subtalar facet coalition. ( D and E ) Surgical treatment with triple arthrodesis
restored rearfoot relationships and eliminated pain.
358 THE JOURNAL OF FOOT & ANKLE SURGERY
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 19/33
Peroneal Spastic Flatfoot Without Coalition
( Pathway 5 )
Peroneal spastic flatfoot without coalition is a painful foot
deformity made rigid by spasm of the extrinsic muscles.
Although tarsal coalition is the most common cause of
peroneal spastic flatfoot (see Pathway 4) (123–132), its
presence cannot be confirmed in a number of cases. Otherpossible causes (133) include juvenile chronic arthritis
(134), osteochondral fractures in the rearfoot, osteoid os-
teoma, neoplasms (135), dysplasia epiphysealis hemimelica
(Trevor disease) (136), and problems more proximal in the
limb (slipped capital femoral epiphysis) (137). When no
cause can be found, the condition has been labeled idio-
pathic peroneal spastic flatfoot.
Significant History ( Pathway 5, Node 1)
The patient develops pain in the foot, followed by pro-
tective limitation of motion by the extrinsic muscles. Pain isexperienced with activity, and symptoms may be precipi-
tated by trauma. Many patients have been previously eval-
uated for tarsal coalition, but there have been no objective or
imaging findings to support the diagnosis.
Significant Findings ( Pathway 5, Node 2)
Peroneal muscle spasm, restricted subtalar and ankle mo-
tion, valgus appearance of the foot, and constant or inter-
mittent pain in response to activity are the hallmarks of the
condition. Clinical findings are not limited to the peroneal
muscles alone. The extensors, tibialis anterior, and tibialisposterior are involved.
Gait pattern is antalgic with external rotation of the foot
to the line of progression. There is little or no propulsion
during late stance phase of gait.
Diagnostic Studies ( Pathway 5, Node 3)
Diagnostic imaging that fails to show a tarsal coalition or
typical secondary findings of a tarsal coalition (see Pathway
4) may show other pathologies that might explain the con-
dition such as osteochondral defect, pathologic fracture
through a bone cyst, or osteomyelitis (Fig 12).A preliminary bone scan may help localize the pathology.
A total body bone scan is useful to rule out otherwise silent
multiple anatomical sites in systemic disease. In some cases,
all imaging studies may be normal and further clinical
investigation is indicated.
Laboratory studies (Node 4) should include a complete
blood cell count with differential and acute phase reactants
(erythrocyte sedimentation rate and C-reactive protein). El-
evated inflammatory markers suggest a rheumatologic cause
and merit further investigation or consultation (Node 5).
Diagnosis ( Pathway 5, Node 6)
Peroneal spastic flatfoot without coalition is a diagnosis
of exclusion and may be ultimately considered idiopathic.
Initial Treatment ( Pathway 5, Node 7)
When a specific cause is detected, appropriate treatment
is directed toward that cause. If no cause can be identified,
symptoms dictate the type of treatment. When symptoms
are intermittent, activity modifications may prove useful.
This may include stopping sports, discouraging running and
jumping activities, and taking the child out of physical
education class. Activity modifications can be supple-
mented with nonsteroidal antiinflammatory medications.
Footwear modifications, arch supports, and orthosis mayalso be beneficial.
In more difficult cases, immobilization in a walking boot
may prove helpful. However, patient compliance is often a
problem. This can be solved with a nonweightbearing be-
low-knee cast and crutches. In extreme cases, an above-
knee cast can be considered. Common peroneal nerve
blocks can be both therapeutic and diagnostic.
Clinical Response ( Pathway 5, Node 8)
If clinical response to treatment results in resolution of
the symptoms and restoration of painless range of mo-tion, follow-up orthotic treatment may be indicated and
the patient should be observed periodically (Nodes 9 and
10).
Surgical Intervention ( Pathway 5, Node 11)
If symptoms do not resolve with nonsurgical treatment,
surgical options can be considered (Node 11). Surgical
procedures include arthrodesis and realignment osteotomy.
Observation and supportive orthoses should follow surgery
(Node 10).
Iatrogenic and Posttraumatic Deformit y ( Pathway 6 )
Iatrogenic and posttraumatic flatfoot are uncommon
and encompass a broad spectrum of foot disorders. Man-
agement can be challenging and complex, necessitating
case-by-case consideration. Surgical treatment of infant
foot deformities often results in undercorrection or over-
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 359
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 20/33
PATHWAY 5
360 THE JOURNAL OF FOOT & ANKLE SURGERY
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 21/33
correction. This is particularly true for talipes equinova-
rus (138–144). The goal of treatment is a flexible, plan-
tigrade, painless foot. In many cases, a perfect outcome is
not possible. Often, the end result is a rigid and, hope-
fully, plantigrade foot.
Etiologic factors include overcorrected clubfoot (Fig 13),
undercorrected vertical talus (145–148), failed flatfoot sur-
gery, and end-stage trauma. Iatrogenic or posttraumatic
flatfoot may also be caused by manipulation or casting of
the pliable, easily damaged infant foot.
FIGURE 12 Rigid flatfoot deformity with peroneal spasm may
occur in the absence of coalition. Multiple etiologies have been
implicated. ( A ) This is an adolescent patient with a medial talar
dome lesion that produced the patient’s symptoms and ( B )
flatfoot deformity. Other pathologies include lesions of rearfoot
bones. ( C and D ) Plain films and CT images of an osteoid
osteoma of the talar neck that produced a symptomatic rigid
flatfoot.
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 361
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 22/33
PATHWAY 6
362 THE JOURNAL OF FOOT & ANKLE SURGERY
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 23/33
Significant History ( Pathway 6, Node 1)
Patients with iatrogenic or posttraumatic flatfoot present
with variable degrees of pain, loss of function, and progres-
sive deformity. All feet in this category have a history of
previous manipulation, surgery, or trauma. Onset of flatfoot
deformity may be either immediate or delayed by months oryears.
Significant Findings ( Pathway 6, Node 2)
Examination may determine pain, stiffness, scarring, ab-
normal function, and gait disturbances.
Diagnostic Imaging ( Pathway 6, Node 3)
Plain radiographs may show postsurgical changes, re-
tained implants and hardware, malalignment, and arthri-
tis. CT, MRI, and bone scans may be useful in further
defining the deformity and in evaluating residual pathol-
ogy.
Diagnosis ( Pathway 6, Node 4)
The patient’s history, coupled with diagnostic imaging, con-
firms the diagnosis of iatrogenic or posttraumatic flatfoot.
Initial Treatment ( Pathway 6, Node 5)
Shoe modifications and bracing may be indicated in the
initial management of these deformities. Activity modifica-
tions, weight reduction, physical therapy, and nonsteroidal
antiinflammatory medication may be helpful.
Clinical Response ( Pathway 6, Node 6)
If the clinical response is satisfactory, continued nonsurgical
management and observation are in order (Nodes 7 and 8).
Surgical Intervention ( Pathway 6, Node 9)
If there is no response to nonsurgical treatment, surgical
intervention (Node 9) may be necessary to achieve the goal of
a stable pain-free plantigrade foot. The specific procedures aredirected to the deformity, the condition of the soft tissues, and
the joints and osseous structures. Patient and parental educa-
tion should be provided to encourage realistic expectations.
Soft tissue release, osteotomy, and arthrodesis (145–148)
are the procedures most frequently used. In certain cases,
severe deformities may be realigned with distraction osteo-
genesis (Ilizarov) (139). Rarely, in the case of intractable
pain and unstable deformity or chronic osteomyelitis, an
FIGURE 13 ( A and B ) The long-term results of posteromedial release of clubfoot deformity.
There has been overcorrection, resulting in rigid flatfoot deformity and marked sagittal breechwith subluxation of the talonavicular articulation. The first ray is supinated with metatarsus primus
elevatus.
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 363
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 24/33
amputation followed by a functional prosthesis is a reason-
able choice to allow the patient to return to activities.
Patients should be followed up for observation (Node 8).
Recurrence is possible and necessitates reevaluation.
Skewfoot ( Pathway 7 )
Skewfoot is characterized by forefoot adduction (meta-tarsus adductus) and heel valgus (149–151). The more
severe cases have midfoot abduction. There are no univer-
sally accepted clinical or radiographic criteria for skewfoot
(150) and the natural history of idiopathic skewfoot is
poorly understood (150, 152, 153). There are 4 types of
skewfoot: congenital idiopathic, congenital associated with
syndromes, neurogenic, and iatrogenic (151).
Significant History ( Pathway 7, Node 1)
Skewfoot may be asymptomatic or associated with
activity-related pain and difficulty in fitting shoes (150,154). It is often misdiagnosed as metatarsus adductus and
flexible flatfoot. Skewfoot should be suspected if the
infant does not respond favorably to treatment for meta-
tarsus adductus.
Significant Findings ( Pathway 7, Node 2)
The deformity is characterized as an S- or Z-shaped foot
with forefoot adductovarus and rearfoot valgus (149) (Fig 14).
In children younger than 1 year of age, the rearfoot valgus is
not as apparent as the forefoot deformity (151). Contracture of
the tendo-Achilles may be present (150, 151). Calluses and
other skin problems may occur (150, 154).
Diagnostic Imaging ( Pathway 7, Node 3)
Standard radiographs show metatarsus adductus and se-
vere heel valgus (Fig 14).
Diagnosis ( Pathway 7, Node 4)
Clinical findings and supportive radiographs confirm the
diagnosis of skewfoot.
Initial Treatment ( Pathway 7, Node 6)
Asymptomatic skewfoot in older children needs no treat-
ment (Node 5). Management of skewfoot is based on age,
degree of severity, and presence of symptoms (155). Ma-
nipulation and serial casting may be indicated for infants
(155). Stretching exercises and activity modification may
relieve mild symptoms but they will not change the defor-
mity (150). Orthoses may be used for symptomatic relief but
may exacerbate the symptoms in the presence of ankle
equinus (150). Nonsteroidal antiinflammatory medications
may also be beneficial. Management of comorbid condi-
tions is important.
Clinical Response ( Pathway 7, Node 7)
Clinical response to treatment is evaluated. Observation
and continuation of initial treatment options are recom-
mended for children whose symptoms resolve (Node 8).
Surgical Intervention ( Pathway 7, Node 9)
Persistence of severe symptoms may require surgical
intervention. Surgical treatment must address both the fore-
foot and the rearfoot components (Fig 15). Useful proce-
dures include metatarsal osteotomies and midfoot osteot-
omy to correct the forefoot. Lateral column lengthening,
calcaneal displacement osteotomy, and tendo-Achilles
lengthening are used to correct the rearfoot (149–151,
155, 156).
364 THE JOURNAL OF FOOT & ANKLE SURGERY
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 25/33
PATHWAY 7
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 365
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 26/33
FIGURE 14 Skewfoot, an uncommon but very severe variant of the flatfoot deformity, is characterized by rearfoot pronation, midfoot abduction,
and metatarsus adductus. ( A ) This clinical photograph of an adolescent patient with skewfoot shows forefoot adduction—unlike forefoot abduction
seen with most other flatfoot deformities. ( B ) The AP radiograph shows very prominent metatarsus adductus deformity with a large talocalcaneal
angle. ( C ) The lateral radiograph shows sagittal plane failure of the medial column with talar ptosis (pathologic declination).
366 THE JOURNAL OF FOOT & ANKLE SURGERY
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 27/33
FIGURE 15 Surgical treatment of skewfoot requires addressing the forefoot and rearfoot
pathologies separately. ( A ) The AP radiograph is generally diagnostic. There is a Z orientation of
the rearfoot, midfoot, and forefoot areas. ( B ) The lateral radiograph shows the typical findings of
pronatory deformity. ( C and D ) AP and lateral radiographs show the surgical results of meta-
tarsal–first cuneiform arthrodesis in combination with lesser metatarsal osteotomies to correct
the metatarsus adductus, and a lateral column lengthening osteotomy of the calcaneus (Evans
procedure).
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 367
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 28/33
Other Causes of Pediatric Flatfoot ( Pathway 8 )
Some forms of pediatric flatfoot deformity do not fit
into the previous schemes. They are unique because their
clinical findings are dictated by the underlying pathology.
Additionally, the clinical approach to diagnosis and treat-
ment is dependent on the cause. Some have natural
histories that are totally unpredictable, and early inter-vention is undesirable until the problem has fully ex-
pressed itself.
Significant History ( Pathway 8, Node 1)
These forms of pediatric flatfoot are associated with
generalized ligamentous laxity; Marfan disease; Ehlers-
Danlos; and Down syndrome, cerebral palsy, myelomenin-
gocele, developmental delay, genetic diseases, and other
syndromes (Fig 16).
Significant Findings ( Pathway 8, Node 2)
A variable pattern of foot deformities may be seen. Thedeformities range from hypermobile to rigid. Physical ex-
amination of these children must include observational gait
analysis, assessment of generalized joint mobility for hy-
perlaxity and hypolaxity, and thorough neurologic exami-
nation. Examination of the foot for mobility, calluses, and
skin irritation is necessary.
Diagnostic Imaging ( Pathway 8, Node 3)
Diagnostic imaging should be performed as clinically
indicated.
Diagnosis ( Pathway 8, Node 4)
There is nothing unique about this group of pathologies
that has not been previously discussed. Refer to previous
pathways for detailed discussion.
Initial Treatment ( Pathway 8, Node 6)
In planning the treatment of flatfoot in children with
underlying diseases, it is important to consider the patient’s
baseline function, the demands placed on the feet, and the
natural history of the underlying disease. Asymptomatic
hypermobile flatfeet in syndromatic children are usually
best left alone (Node 5).
Treatment is based on structural deformity and func-
tional demands placed on the foot. Treatment is usually
indicated if the child is ambulating or likely to become
ambulatory. Children with an unstable base of support
secondary to flatfoot may be treated with supportive
orthoses (Node 7).
Surgical Intervention ( Pathway 8, Node 8)
If bracing is not tolerated or does not provide a solid base
of support, surgical intervention may be considered. Surgi-
cal options are aimed at the specific pathoanatomy and
include osteotomies, arthrodesis, arthroereisis, and tendon
transfers. Long-term orthosis management after surgical
intervention is usually recommended to maximize function
(Node 7).
368 THE JOURNAL OF FOOT & ANKLE SURGERY
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 29/33
PATHWAY 8
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 369
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 30/33
FIGURE 16 Flatfoot deformities in combination with systemic disease and syndromic patterns may be extremely difficult to treat. ( A )
Children with congenital myotonic dystrophy show characteristic facial weakness with a cupid bow mouth and inexpressive appearance. ( B )
Pronatory foot deformities are a regular feature shown clinically by excessive relaxed calcaneal stance position. ( C and D ) AP and lateral
radiographs show typical features of severe flatfoot deformity. ( E ) This is the standing lateral photograph of an 8-year-old with chromosomal
abnormality, showing pronation with equinus. ( F and G ) The AP and lateral radiographs show complex midfoot and rearfoot coalitions. ( H–L )
Shown is a boy with a congenital ball-and-socket ankle with a talonavicular coalition and absence of a lateral ray. Hindfoot instability with
a valgus heel and forefoot abduction are shown clinically and radiographically.
370 THE JOURNAL OF FOOT & ANKLE SURGERY
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 31/33
References
1. Trott AW. Children’s foot problems. Orthop Clin North Am 13:641–
654, 1982.
2. Caselli MA, Sobel E, McHale KA. Pedal manifestations of musculo-
skeletal disease in children. Clin Podiatr Med Surg 15:481–497, 1998.
3. Harris EJ. The oblique talus deformity. What is it, and what is its
clinical significance in the scheme of pronatory deformities? Clin
Podiatr Med Surg 17:419–442, 2000.4. Hefti F. Foot pain. Orthopade 28:173–179, 1999.
5. Jayakumar S, Cowell HR, Ramsey P. Foot problems in children. Part
1. Vertical and oblique talus. Instr Course Outline 31:235–251, 1985.
6. Jayakumar S, Ramsey P. Vertical and oblique talus: a diagnostic
dilemma. Orthop Trans 1:108, 1977.
7. Sullivan JA. Pediatric flatfoot: evaluation and management. J Am
Acad Orthop Surg 7:44–53, 1999.
8. Tonnis D. Skewfoot. Orthopade 15:174–183, 1986.
9. Napolitano C, Walsh S, Mahoney L, McCrea J. Risk factors that may
adversely modify the natural history of the pediatric pronated foot.
Clin Podiatr Med Surg 17:397–417, 2000.
10. Sullivan RW. Correction of the hypermobile flatfoot by the subtalar
arthroeresis procedure. Mil Med 150:546–548, 1985.
11. Jani L. Pediatric flatfoot. Orthopade 15:199–204, 1986.
12. Bahler A. Insole management of pediatric flatfoot. Orthopade 15:205–211, 1986.
13. Cappello T, Song KM. Determining treatment of flatfeet in children.
Curr Opin Pediatr 10:77–81, 1998.
14. Staheli LT. Planovalgus foot deformity. Current status. J Am Podiatr
Med Assoc 89:94–99, 1999.
15. Anderson AF, Fowler SB. Anterior calcaneal osteotomy for symp-
tomatic juvenile pes planus. Foot Ankle 4:274–283, 1984.
16. Bruyn JM, Cerniglia MW, Chaney DM. Combination of Evans calca-
neal osteotomy and STA-Peg arthroereisis for correction of the severe
pes valgo planus deformity. J Foot Ankle Surg 38:339–346, 1999.
17. Cohen-Sobel E, Giorgini R, Velez Z. Combined technique for sur-
gical correction of pediatric severe flexible flatfoot. J Foot Ankle
Surg 34:183–194, 1995.
18. Dockery GL. Surgical treatment of the symptomatic juvenile flexible
flatfoot condition. Clin Podiatr Med Surg 4:99–117, 1987.19. Dockery GL. Symptomatic juvenile flatfoot condition: surgical treat-
ment. J Foot Ankle Surg 34:135–145, 1995.
20. Mahan KT, McGlamry ED. Evans calcaneal osteotomy for flexible
pes valgus deformity. A preliminary study. Clin Podiatr Med Surg
4:137–151, 1987.
21. Roye DP Jr, Raimondo RA. Surgical treatment of the child’s and
adolescent’s flexible flatfoot. Clin Podiatr Med Surg 17:515–530,
2000.
22. Smith SD, Millar EA. Arthrorisis by means of a subtalar polyethylene
peg implant for correction of hindfoot pronation in children. Clin
Orthop 181:15–23, 1983.
23. Lundeen RO. The Smith STA-peg operation for hypermobile pes
planovalgus in children. J Am Podiatr Med Assoc 75:177–183, 1985.
24. Forg P, Feldman K, Flake E, Green DR. Flake-Austin modification of
the STA-Peg arthroereisis: a retrospective study. J Am Podiatr MedAssoc 91:394–405, 2001.
25. Maxwell JR, Carro A, Sun C. Use of the Maxwell-Brancheau arthro-
ereisis implant for the correction of posterior tibial tendon dysfunc-
tion. Clin Podiatr Med Surg 16:479–489, 1999.
26. Lepow GM, Smith SD. A modified subtalar arthroereisis implant for
the correction of flexible flatfoot in children. The STA Peg procedure.
Clin Podiatr Med Surg 6:585–590, 1989.
27. Smith SD, Ocampo RF. Subtalar arthrorisis and associated proce-
dures. Clin Podiatr Med Surg 14:87–98, 1997.
28. Vedantam R, Capelli AM, Schoenecker PL. Subtalar arthroereisis for
the correction of planovalgus foot in children with neuromuscular
disorders. J Pediatr Orthop 18:294–298, 1998.
29. Rockett AK, Mangum G, Mendicino SS. Bilateral intraosseous cystic
formation in the talus: a complication of subtalar arthroereisis. J Foot
Ankle Surg 37:421–425, 1998.
30. Thompkins MH, Nigro JS, Mendicino S. The Smith STA-peg: a
7-year retrospective study. J Foot Ankle Surg 32:27–33, 1993.
31. Crawford AH, Gabriel KR. Foot and ankle problems. Orthop Clin
North Am 18:649–666, 1987.
32. Giorgini RJ, Schiraldi FG, Hernandez PA. Subtalar arthroereisis: a
combined technique. J Foot Surg 27:157–161, 1988.
33. Giannini S, Kenneth A. Johnson Memorial Lecture. Operative treatment
of the flatfoot: why and how. Foot Ankle Int 19:52–58, 1998.
34. Grady JF, Dinnon MW. Subtalar arthroereisis in the neurologically
normal child. Clin Podiatr Med Surg 17:443–457, 2000.
35. Langford JH, Bozof H, Horowitz BD. Subtalar arthroereisis. Valente
procedure. Clin Podiatr Med Surg 4:153–161, 1987.
36. Lombardi CM, Silver LM, Silhanek AD, Connolly FG, Ramcharitar
SI. Treatment of congenital convex pes valgus with navicular exci-
sion and subtalar arthroereisis: a case study. J Foot Ankle Surg
40:166 –171, 2001.
37. Smith SD, Wagreich CR. Review of postoperative results of the
subtalar arthrorisis operation: a preliminary study. J Foot Surg 23:
253–260, 1984.38. Smith PA, Millar EA, Sullivan RC. Sta-Peg arthroereisis for treat-
ment of the planovalgus foot in cerebral palsy. Clin Podiatr Med Surg
17:459–469, 2000.
39. Crego CH Jr, Scheer GE. A two-stage stabilization procedure for cor-
rection of calcaneocavus. J Bone Joint Surg Am 38A:1247–1253, 1956.
40. Sekiya JK, Saltzman CL. Long term follow-up of medial column
fusion and tibialis anterior transposition for adolescent flatfoot defor-
mity. Iowa Orthop J 17:121–129, 1997.
41. Broughton NS, Graham G, Menelaus MB. The high incidence of foot
deformity in patients with high level spina bifida. J Bone Joint Surg
76B:548–550, 1994.
42. Specht EE. Congenital paralytic vertical talus. An anatomical study.
J Bone Joint Surg 57A:842–847, 1975.
43. Westcott MA, Dynes MC, Remer EM, Donaldson JS, Dias LS.
Congenital and acquired orthopedic abnormalities in patients withmyelomeningocele. Radiographics 12:1155–1173, 1992.
44. Green NE, Lowery ER, Thomas R. Orthopaedic aspects of prune
belly syndrome. J Pediatr Orthop 13:496 –501, 1993.
45. Stanton RP, Rao N, Scott CIJ. Orthopedic manifestations in de Barsy
syndrome. J Pediatr Orthop 14:60–62, 1994.
46. Bamshad M, Bohnsack JF, Jorde LB, Carey JC. Distal arthrogryposis
type 1: clinical analysis of a large kindred. Am J Med Genet 65:282–
285, 1996.
47. Guidera KJ, Drennan JC. Foot and ankle deformities in arthrogrypo-
sis multiplex congenita. Clin Orthop 194:93–98, 1985.
48. Ashley RK, Larsen LJ, Waskow SB, Schnaser A. Congenital metacar-
potalar syndrome. Ann Acad Med Singapore 10:434–441, 1981.
49. Haberlandt E, Loffler J, Hirst-Stadlmann A, Stockl B, Judmaier W,
Fischer H, Heinz-Erian P, Muller T, Utermann G, Smith RJ, Janecke
AR. Split hand/split foot malformation associated with sensorineural
deafness, inner and middle ear malformations, hypodontia, congenital
vertical talus, and deletion of eight microsatellite markers in 7q21.1-
q21.3. J Med Genet 38:495–499, 2001.
50. Julia S, Pedespan JM, Boudard P, Barbier R, Gavilan-Cellie J,
Chatiel JF, Lacombe D. Association of external auditory canal atre-
sia, vertical talus, and hypertelorism: confirmation of rasmussen
syndrome. Am J Med Genet 110:178–181, 2002.
51. Rasmussen N, Johnsen NJ, Thomsen J. Inherited congenital bilateral
atresia of the external auditory canal, congenital bilateral vertical
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 371
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 32/33
talus and increased interocular distance. Acta Otolaryngol
88:296 –302, 1979.
52. Kodros SA, Dias LS. Single-stage surgical correction of congenital
vertical talus. J Pediatr Orthop 19:42– 48, 1999.
53. Daumas L, Felipe G, Carlioz H. Congenital convex talus. Methods
and results of a single-stage surgical correction. Rev Chir Orthop
Reparatice Appar Mot 81:527–537, 1995.
54. Dodge LD, Ashley RK, Gilbert GJ. Treatment of the congenital
vertical talus: a retrospective review of 36 feet with long-term follow-
up. Foot Ankle 7:326–332, 1987.55. Hamanishi C. Congenital vertical talus: classification with 69 cases
and new measurement system. J Pediatr Orthop 4:318–326, 1984.
56. Kranicz J, Bellyei A, Szabo G. Vertical Talus. Magy Traumatol
Orthop Helyreallito Serb 34:319–323, 1991.
57. Lichtblau S. Congenital vertical talus. Bull Hosp Joint Dis 39:165–
179, 1978.
58. Ogata K, Schoenecker PL, Sheridan J. Congenital vertical talus and
its familial occurrence: an analysis of 36 patients. Clin Orthop 139:
128–132, 1979.
59. Wirth T, Schuler P, Griss P. Early surgical treatment of congenital
vertical talus. Arch Orthop Trauma Surg 113:248–253, 1994.
60. Yen CC, Huang SC. Surgical treatment of congenital convex pes
valgus. J Formos Med Assoc 96:424–428, 1997.
61. Zorer G, Bagatur AE, Dogan A. Single stage surgical correction of
congenital vertical talus by complete subtalar release and peritalar
reduction by using the Cincinnati incision. J Pediatr Orthop B 11:
60– 67, 2002.
62. Klein DM, Merola AA, Spero CR. Congenital vertical talus with a
talocalcaneal coalition. J Bone Joint Surg 78B:326–327, 1996.
63. Dobbs MB, Schoenecker PL, Gordon JE. Autosomal dominant trans-
mission of isolated congenital vertical talus. Iowa Orthop J 22:25–27,
2002.
64. Stern HJ, Clark RD, Stroberg AJ, Shohat M. Autosomal dominant
transmission of isolated congenital vertical talus. Clin Genet 36:427–
430, 1989.
65. Adelaar RS, Williams RM, Gould JS. Congenital convex pes valgus:
results of an early comprehensive release and a review of congenital
vertical talus at Richmond Crippled Children’s Hospital and the
University of Alabama in Birmingham. Foot Ankle 1:62–73, 1980.
66. Oppenheim W, Smith C, Christie W. Congenital vertical talus. Foot
Ankle 5:198–204, 1985.
67. Salo JM, Viladot A, Garcia-Elikas M, Sanchez-Freijo JM, Viladot R.
Congenital flat foot: different clinical forms. Acta Orthop Belg 58:
406–410, 1992.
68. Badelon O, Rigault P, Pouliquen JC, Padovani JP, Guyonvarch J.
Congenital convex clubfoot: a diagnostic and therapeutic study of 71
cases. Int Orthop 8:211–221, 1984.
69. Benard MA. Congenital vertical talus. Clin Podiatr Med Surg 17:
471–480, 2000.
70. Jacobsen ST, Crawford AH. Congenital vertical talus. J Pediatr
Orthop 3:306–310, 1983.
71. Marcinko DE, Azzolini TJ, Mariash SA. Enigma of pediatric vertical
talus deformity. J Foot Surg 29:452–458, 1990.
72. Hammel J. Ultrasound diagnosis of congenital foot deformities. Or-
thopade 31:326–327, 2002.
73. Hammel J, Grossmann P, Schramm J, Becker W. Sonographic diag-
nosis of the juvenile tarsus. Clinical application possibilities demon-
strated by examples. Orthop Ihre Grenzgeb 133:43–49, 1995.
74. Schlesinger AE, Deeney VF, Caskey PF. Sonography of the nonos-
sified tarsal navicular cartilage in an infant with congenital vertical
talus. Pedtatr Radiol 20:134 –135, 1989.
75. Schlesinger AE, Hernandez RJ. Diseases of the musculoskeletal
system in children: imaging with CT, sonography, and MR. Am J
Roentgenol 158:729–741, 1992.
76. Greenberg AJ. Congenital vertical talus and congenital calcaneoval-
gus deformity: a comparison. J Foot Surg 20:189–193, 1981.
77. Griffin DW, Daly N, Karlin JM. Clinical presentation of congenital
convex pes valgus. J Foot Ankle Surg 34:146–152, 1995.
78. Fitton JM, Nevelos AB. The treatment of congenital vertical talus.
J Bone Joint Surg 61B:481–483, 1979.
79. Schrader LF, Gilbert RJ, Skinner SR, Ashley RK. Congenital vertical
talus: surgical correction by one-stage medial approach. Orthopedics
13:1233–1236, 1990.
80. Stricker SJ, Rosen E. Early one-stage reconstruction of congenital
vertical talus. Foot Ankle Int 18:525–543, 1997.
81. Walker AP, Ghali NN, Silk FF. Congenital vertical talus. The results
of staged operative reduction. J Bone Joint Surg 67B:117–121, 1985.
82. Seimon LP. Surgical correction of congenital vertical talus under the
age of 2 years. J Pediatr Orthop 7:405–411, 1987.
83. Simons GW. The complete subtalar release in clubfeet. Orthop Clin
North Am 18:667–688, 1987.
84. Clark MW, D’Ambrosia RD, Ferguson AB. Congenital vertical talus:
treatment by open reduction and navicular excision. J Bone Joint
Surg 59A:816–824, 1977.
85. Lombardi CM, Silver LM, Silhanek A.D., Connolly F.G., Ramchari-
tar S.I. Treatment of congenital convex pes valgus with navicular
excision and subtalar arthroeresis: a case study J Foot Ankle Surg
40:166–171/sb:last-page2001]?86. Robbins H. Naviculectomy for congenital vertical talus. Bull Hosp
Joint Dis 37:77–97, 1976.
87. Marciniak W. Results of surgical peritalar release with elongation of
the lateral column of the foot in treatment of congenital vertical talus.
Chir Narzadow Ruchu Ortop Pol 58:189–193, 1993.
88. McCall RE, Lillich JS, Harris JR, Johnston FA. The Grice extraar-
ticular subtalar arthrodesis: a clinical review. J Pediatr Orthop 5:442–
445, 1985.
89. Napiontek M. Congenital vertical talus: a retrospective and critical
review of 32 feet operated on by peritalar reduction. J Pediatr Orthop
B 4:179–187, 1995.
90. Kulik SA Jr, Clanton TO. Tarsal coalition. Foot Ankle Int 17:286 –
296, 1996.
91. Thometz J. Tarsal coalitions. Foot Ankle Clin 5:103–117, 2002.
92. Cohen BE, Davis WH, Anderson RB. Success of calcaneonavicularcoalition resection in the adult population. Foot Ankle Int 17:569–
572, 1996.
93. Jayakumar S, Cowell HR. Rigid flatfoot. Clin Orthop 122:77–84,
1977.
94. Scranton PE Jr. Treatment of symptomatic talocalcaneal coalition.
J Bone Joint Surg 69A:533–539, 1987.
95. Botine WH. Tarsal coalition. Curr Opin Pediatr 13:29–35, 2001.
96. Leonard MA. The inheritance of tarsal coalition and its relationship
to spastic flat foot. J Bone Joint Surg 56B:520–526, 1974.
97. Mosier KM, Asher M. Tarsal coalitions and peroneal spastic flat foot.
A review. J Bone Joint Surg 66A:976–984, 1984.
98. Olney BW. Tarsal coalition. In The Child’s Foot and Ankle, p 169,
edited by JC Drennan, Raven Press, New York, 1992.
99. Olney B, Asher M. Excision of symptomatic coalition of the middle
facet of the talocalcaneal joint. J Bone Joint Surg 69A:538–544,
1987.
100. Lateur LM, VanHoe LR, Ghellewe KV, Gryspeerdt SS, Baert AC,
Dereymaaker GC. Subtalar coalition: diagnosis with the C sign on
lateral radiographs of the ankle. Radiology 193:847–851, 1994.
101. Cowell HR. Diagnosis and management of peroneal spastic flatfoot.
Instr Course Lect 24:93–103, 1975.
102. Cowell HR. Tarsal coalition—review and update. Instr Course Lect
31:264 –271, 1982.
103. Emery KH, Bisset G Sr, Johnson ND, Nunan PJ. Tarsal coalition: a
372 THE JOURNAL OF FOOT & ANKLE SURGERY
8/10/2019 Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot
http://slidepdf.com/reader/full/harris-et-al-2004-diagnosis-and-treatment-of-pediatric-flatfoot 33/33
blinded comparison of MRI and CT. Pediatric Radiology
28:612–616, 1998.
104. Hochman M, Reed MH. Features of calcaneonavicular coalition on
coronal computed tomography. Skeletal Radiol 29:409– 412, 2000.
105. Solomon LB, Ruhli FJ, Taylor J, Ferris L, Henneberg M. A dissection
and computer tomograph study of tarsal coalitions in 100 cadaver
feet. J Orthop Res 21:352–358, 2003.
106. Herzenberg JE, Goldner JL, Martinez S, Silverman PM. Computer-
ized tomography of talocalcaneal tarsal coalition: a clinical and
anatomic study. Foot Ankle 6:273–288, 1896.107. Lomasny LM, Demos TC, Harris EJ. Computed tomographic imag-
ing of the foot and ankle. Developmental and congenital anomalies.
J Am Podiatr Med Assoc 90:223–233, 2000.
108. Masciocchi C, D’Archivo C, Barile A. Talocalcaneal coalition: com-
puterized tomography and magnetic resonance imaging diagnosis.
Eur J Radiol 15:22–25, 1992.
109. Pineda C, Resnick D, Greenway G. Diagnosis of tarsal coalition with
computed tomography. Clin Orthop July 208:282–288, 1986.
110. Snyder RB, Lipscomb AB, Johnston RK. The relationship of tarsal
coalitions to ankle sprains in athletes. Am J Sports Med 9:313–317,
1981.
111. Stoskopf CA, Hernandez RJ, Kelikian A, Tachdjian MO, Dias LS.
Evaluation of tarsal coalition by computed tomography. J Pediatr
Orthop 4:365–369, 1984.
112. Warren MJ, Jeffree MA, Wilson DL, MacLarnon JC. Computedtomography in suspected tarsal coalition. Examination of 26 cases.
Acta Orthop Scand 61:554–557, 1990.
113. Munk PL, Vellet AD, Levin MF, Helmes CA. Current status of
magnetic resonance imaging of the ankle and hindfoot. Can J Radiol
43:19–30, 1992.
114. Newman JS, Newberg AH. Congenital tarsal coalition: multimodality
evaluation with emphasis on CT and MR imaging. Radiographics
20:321–332, 2000.
115. Pachuda NM, Laday SO, Jay RM. Tarsal coalition: etiology, diag-
nosis and treatment. J Foot Surg 29:474–488, 1990.
116. Weschler RJ, Schweitzer ME, Deely DM, Horn BD, Pizzutillo PD.
Tarsal coalition: depiction and characterization with CT and MR
imaging. Radiology 193:447–452, 1994.
117. de Lima RT, Mishkins FS. The bone scan in tarsal coalition: a case
report. Pediatric Radiology 26:754–756, 1996.118. Deutsch AL, Resnick D, Campbell G. Computed tomography and
bone scintigraphy in the evaluation of tarsal coalition. Radiology
144:137–140, 1982.
119. Goldman AR, Pavlov H, Schneider R. Radionuclide bone scanning in
subtalar coalitions & differential considerations. Am J Roentgenol
138:427–432, 1982.
120. Elkus RA. Tarsal coalition in the young athlete. Am J Sports Med
14:477–480, 1986.
121. Harris RI, Beath T. Etiology of peroneal spastic flatfoot. J Bone Joint
Surg 30B:624–634, 1948.
122. Morgan RC, Crawford AH. Surgical management of tarsal coalition
in adolescent athletes. Foot Ankle 7:183–193, 1986.
123. Angostinelli JR. Tarsal coalition and its relationship to peroneal
spastic flatfoot. J Am Podiatr Med Assoc 76:76–80, 1986.
124. Barroso JL, Barriga A, Barrecheguren EG, Villas C, BeguiristainJL. Congenital synostoses of the tarsus. Concept, classification,
diagnosis and therapeutic approach. Rev Med Univ Navarra 45:
43–52, 2001.
125. Bohne WH. Tarsal coalition. Curr Opin Pediatr 13:29 –35, 2001.
126. Cowell HR. Talocalcaneal coalition and new causes of peroneal
spastic flatfoot. Clin Orthop 85:16–22, 1972.
127. Dungl P. The flatfoot in children—pes planovalgus. Acta Chir Orthop
Traumatol Cech 55:536 –548, 1988.
128. Kelo MJ, Riddle DL. Examination and management of a patient with
tarsal coalition. Phys Ther 78:518–525, 1998.
129. Jacobs AM, Sollecito V, Oloff L, Klein N. Tarsal coalitions: an
instructional review. J Foot Surg 20:214 –221, 1981.
130. Lahey MD, Zindrick MR, Harris EJ. A comparative study of the
clinical presentation of tarsal coalitions. Clin Podiatr Med Surg
5:341–357, 1988.
131. Page JC. Symptomatic flatfoot. Etiology and diagnosis. J Am Podi-
atry Assoc 73:393–399, 1983.
132. Stormont DM, Peterson HA. The relative incidence of tarsal coali-
tion. Clin Orthop 181:28–36, 1983.
133. Lowy LJ. Pediatric peroneal spastic flatfoot in the absence of coali-
tion. A suggested protocol. J Am Podiatr Med Assoc 88:181–191,
1998.
134. Glockenberg A, Weinreb A, Pevny J. Rheumatoid arthritis-induced
peroneal spastic flatfoot. J Am Podiatr Med Assoc 77:185–187, 1987.
135. Johnson JC. Peroneal spastic flatfoot syndrome. South Med J 69:807–
809, 1976.
136. Graves SC, Kuester DJ, Richardson EG. Dysplasia epiphysealis
hemimelica (Trevor disease) presenting as peroneal spastic flatfoot
deformity: a case report. Foot Ankle 12:55–58, 1991.
137. Doig SG, Menelaus MB. Association of slipped upper femoral epiph-
ysis and peroneal spastic flatfoot. J Pediatr Orthop 11:220 –221, 1991.
138. Crawford AH, Gupta AK. Clubfoot controversies: complications andcauses for failure. Instr Course Lect 45:339–346, 1996.
139. Herzenberg JE, Paley D. Ilizarov management of clubfoot deformity
in young children. In Foot and Ankle Clinics, edited by MS Myerson,
Saunders, Philadelphia, 1998.
140. Ponseti IV, Smoley EN. Congenital clubfoot: the results of treatment.
J Bone Joint Surg 45A:82–94, 1963.
141. Ponseti IV. Congenital Clubfoot—Fundamentals of Treatment , Ox-
ford University Press, New York, 1966.
142. Simons GW. The Clubfoot , Springer-Verlag, New York, 1994.
143. Spiegel DA, Mathur SM, Davidson RS. Residual deformities following
the treatment of idiopathic talipes equinovarus. In Foot and Ankle
Clinics, edited by MS Myerson, Saunders, Philadelphia, 1998.
144. Weseley MS, Barenfeld PA, Barrett N. Complications of the treat-
ment of clubfoot. Clin Orthop 84:93–96, 1972.
145. Coleman SS. Complex Foot Deformities in Children, Lea and Fe-bringer, Philadelphia, 1983.
146. Drennan JC. Congenital vertical and oblique talus. In Foot and Ankle
Clinics, edited by MS Myerson, Saunders, Philadelphia, 1998.
147. Silvani SH Congenital convex pes valgus. The condition and its
treatment. Clin Podiatr Med Surg 4:163–173, 1987.
148. Tachdjian MO. Congenital convex pes valgus. Orthop Clin North Am
3:131–148, 1972.
149. Green WB. Metatarsus adductus and skewfoot. Instr Course Lect
43:161–177, 1994.
150. Mosca VS. Flexible flatfoot and skewfoot. Instr Course Lect 45:347–
354, 1996.
151. Napiontek M. Skewfoot. J Pediatr Orthop 22:130–133, 2002.
152. Ponseti IV, Becker JR. Congenital metatarsus adductus: the results of
treatment. J Bone Joint Surg 52A:67–70, 1970.
153. Rushford GF. The natural history of hooked forefoot. J Bone Joint
Surg 60B:530–532, 1978.
154. Mosca VS. Calcaneal lengthening for valgus deformity of the hind-
foot. Results in children who had severe, symptomatic flatfoot and
skewfoot. J Bone Joint Surg 77A:500–512, 1995.
155. Covalier R, Lipton GE, Baden JR. Radiological case study. Ortho-
pedics 20:727–730, 1997.
156. Peterson HA. Skewfoot. J Pediatr Orthop 6:24–30, 1986.