http://upload.medbullets.com/topic/4069/images/Clinical photo - flexible flatfoot - courtesy Miller_moved.png
http://upload.medbullets.com/topic/4069/images/pediatric flex flatfoot normal mearys angle_moved.jpg
  • Physiologic variant consisting of a decrease in the medial longitudinal arch and a valgus hindfoot and forefoot abduction with weightbearing
  • Epidemiology
    • incidence
      • unknown in pediatric population
      • 20% to 25% in adults
  • Pathoanatomy
    • generalized ligamentous laxity is common
    • 25% are associated with gastrocnemius-soleus contracture
  • Prognosis
    • most of the time resolves spontaneously
  • Hypermobile flexible pes planovalgus (most common)
    • familial
      • associated with generalized ligamentous laxity and lower extremity rotational problem
      • usually bilateral
    • associated with an accessory navicular
      • correlation is controversial
  • Flexible pes planovalgus with a tight heel cord 
  • Rigid flatfoot & tarsal coalition (least common)
    • no correction of hindfoot valgus with toe standing due limited subtalar motion
  • Symptoms
    • usually asymptomatic in children
    • may have arch pain or pretibial pain
  • Physical exam
    • inspection
      • foot is only flat with standing and reconstitutes with toe walking, hallux dorsiflexion, or foot hanging   
      • valgus hindfoot deformity
      • forefoot abduction
    • motion
      • normal and painless subtalar motion
      • hindfoot valgus corrects to a varus position with toe standing
      • evaluate for decreased dorsiflexion and tight heel cord
  • Radiographs
    • indications
      • painful flexible flatfoot to rule out other mimicking conditions
        • tarsal coalition (sinus tarsi pain)
        • congenital vertical talus (rocker bottom foot)
        • accessory navicular (focal pain at navicular)
      • rigid flatfoot
    • recommended views
      • required
        • weightbearing AP foot
          • evaluate for talar head coverage and talocalcaneal angle
        • weightbearing lateral foot
          • evaluate Meary's angle
        • weightbearing oblique foot
          • rule out tarsal coalition
      • optional
        • plantar-flexed lateral of foot
          • rules out vertical talus with a line through the long axis of the talus passing above the first metatarsal axis
        • AP and lateral of the ankle
          • if concerned that hindfoot valgus may actually be ankle valgus (associated with myelodysplasia)
    • findings
      • Meary's angle will be apex plantar
        • angle subtended from a line drawn through axis of the talus and axis of 1st ray
  • Tarsal coalition
  • Congenital vertical talus
  • Accessory navicular
  • Nonoperative 
    • observation, stretching, shoewear modification, orthotics
      • indications
        • asymptomatic patients, as it almost always resolves spontaneously
          • counsel parents that arch will redevelop with age
      • techniques
        • athletic heels with soft arch support or stiff soles may be helpful for symptoms 
        • orthotics do not change natural history of disease  
        • UCBL heel cups may be indicated for symptomatic relief of advanced cases
          • rigid material can lead to poor tolerance
        • stretching for symptomatic patients with a tight heel cord
  • Operative
    • Achilles tendon or gastrocnemius fascia lengthening
      • indications
        • flexible flatfoot with a tight heelcord with painful symptoms refractory to stretching
    • calcaneal lengthening osteotomy (with or without cuneiform osteotomy)
      • indications
        • continued refractory pain despite use of extensive conservative management
        • rarely indicated
      • technique
        • calcaneal lengthening osteotomy (Evans)
          • with or without a cuneiform osteotomy and peroneal tendon lengthening
        • sliding calcaneal osteotomy
          • corrects the hindfoot valgus
        • plantar base closing wedge osteotomy of the first cuneiform
          • corrects the supination deformity

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