Box 1 . Red flags in a paediatric flat foot |
Figure 1 . Flat foot . |
Box 2 . General inspection of a child with a flat foot |
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• Asymmetry .
• Severe deformity .
• Worsening deformity .
• Previously normal appearance with new-onset deformity .
• Significant pain not controlled with simple analgesia .
• Rigid deformity .
• Signs / symptoms consistent with neurological , inflammatory causes .
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• Do they have normal facies ?
• Are there any skin abnormalities or birthmarks of note ?
• Are there any stigmata of spinal dysraphism , including scoliotic deformity , when observing their spine ?
• Focusing on their resting posture : — Is there any asymmetry in the way they stand ?
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Red flag features may indicate
that further examination and investigation are necessary to rule out other causes of a paediatric flat foot . If a patient complains of associated back pain with neurological symptoms , generalised weakness , or pain in multiple joints lasting longer than six weeks , then more insidious causes need to be ruled out .
Signs and symptoms
In most instances , there are no significant
pathological signs or symptoms associated with this condition . 4 The age of a patient who presents with flat
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— Do the toes and patellae point in the same direction ?
— Is there overt swelling or heat emanating from any joint , which may be a red flag for infection , trauma or inflammatory conditions ?
• A screen for generalised ligamentous laxity may be completed , observing the degree to which each of their major joints is hypermobile , as this can contribute to persistent flat foot deformity .
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feet on the spectrum of normal devel- |
referral to a paediatric rheumatology |
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opment will range from birth through |
service may be required . |
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to early adolescence ; the time of pres- |
MRI offers the answer in most |
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entation will depend on the degree of |
cases of persistent or concerning |
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parental or patient concern , as well |
deformity , when patients are old |
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as any associated gait abnormality or |
enough to tolerate such imaging . |
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pain . |
It can rule in or out most insidious |
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The earliest presentation tends |
causes of a flat foot . When a patient is |
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to be in the form of calcaneovalgus , |
too young or has claustrophobia and |
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which is present in anywhere between 30 % and 50 % of live births . 4 Parents will present with concerns of an odd |
Figure 2 . Jack test . |
is unable to tolerate the scan without a general anaesthetic , ultrasound may offer some additional information . |
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foot posture noted at birth . This concern is usually addressed by hospital |
Differential diagnosis |
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midwives and obstetricians , but occa- |
ACCESSORY NAVICULAR |
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sionally , patients with mild deform- |
This is a common idiopathic condi- |
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ity may slip through the cracks . This deformity is widely regarded as a ‘ packaging disorder ’ caused by the posture of the child in utero . 4 It is almost always self-resolving , and this |
tion with an autosomal-dominant pattern of inheritance . 4 First presentation is likely to be in adolescents who have experienced a recent direct trauma or overuse injury . Despite the |
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correction can be sped up with the |
medial midfoot prominence having |
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application of ankle joint stretching |
been present most of the child ’ s life , it |
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and massage . While this is not asso- |
is almost never a problem . Accessory |
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ciated with flat foot in the walking child , it may mimic the appearance of congenital vertical talus : one of the conditions not to be missed . 4 The key to differentiating between calcaneo- |
navicular involves enlargement of the plantar and medial navicular . 4 This condition may be a discreet intratendinous ossification separated from the main navicular tuberosity by a |
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valgus and congenital vertical talus |
fibrous or cartilaginous bridge but can |
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is physical examination to determine |
also be continuous via a bony connec- |
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the flexibility or otherwise of the |
tion ( see figure 3 ). |
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equinus and valgus . If the deformity |
Like flat feet themselves , an acces- |
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is supple and correctable , treatment |
sory navicular is typically asymp- |
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consists of reassurance and gentle |
tomatic . Despite this , patients may |
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stretching . If the physical examina- |
notice a bony prominence about the |
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tion is equivocal or the concern is for |
be observed — that is , in children |
and looking to see if the medial arch |
in the case of a correctable flat foot |
medial midfoot that is associated |
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a fixed deformity , plain X-rays may help determine the correct diagnosis . |
not yet able to walk or stand — passive means of determining the flex- |
reconstitutes ( see figure 2 ). Again , asymmetrical findings can be con- |
deformity . That said , plain film X-rays of the foot and ankle — preferably |
with localised pain . The pain can arise from a direct impact , pressure |
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Examination
Examination of the child begins with
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ibility or otherwise of a flat foot are required . Isolate the talocrural and subtalar joints , and mobilise them |
cerning for causes that may need the opinion of a foot and ankle specialist . |
weight-bearing — will afford a safe and , in most cases , effective means of screening for other conditions , |
effect from footwear or associated tendonitis of the tibialis posterior tendon from overuse . |
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a general inspection of the whole |
passively to determine their range of |
If there are any concerns for a neu- |
including congenital vertical talus , |
Diagnosis is confirmed with plain |
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patient ( see box 2 ). |
mobility ( if any ) and then compare |
romuscular or spinal cause for the |
accessory navicular or tarsal coali- |
X-ray and initially treated with sup- |
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Watching the patient walk is |
tion . This test is less specific in the |
portive footwear ; the application of |
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essential for adequate diagnosis . This will allow inspection for any asymmetry in the gait — a red flag for other causes of a flat foot deformity . A pertinent finding on gait examination that may be subtle and often difficult to elicit is the reconstitution |
Watching the patient walk is essential for adequate diagnosis as it allows inspection for any asymmetry in the gait . |
younger age groups because of the developing cartilage and is dependent on the degree of ossification of the tarsal bones .
When a patient complains of pain associated with a flat foot deformity and there are red flags for inflam-
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orthoses in the form of medial arch supports ; and adjuncts , including anti-inflammatory rubs , periods of rest and physiotherapy to strengthen and stretch the associated tendinous structures .
Failing this , referral to an ortho-
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of the medial longitudinal arch and |
matory conditions , blood test for |
paedic-trained foot and ankle special- |
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the heel swinging into a more varus |
inflammatory markers may be a use- |
ist may be required for a discussion |
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attitude — either during the toe-off |
this with the opposite limb . A Jack |
deformity , then conduct a neurologi- |
ful screening tool . FBC , including a |
regarding the possible surgical |
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phase of the gait cycle or on heel ele- |
test can also be useful in engaging |
cal examination of reflexes and power . |
white cell count , as well as CRP and |
solutions . |
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vation . Asking older children to walk on their toes may be a useful trick in this regard . |
the windlass mechanism to reconstitute the arch and pull the hindfoot into varus ; this can be achieved |
Investigation
In the absence of red flags , no rou-
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ESR may help to rule out generalised inflammation or infection as a cause of pain . If these tests indicate gener- |
TARSAL COALITION Tarsal coalition is a failure of segmen- |
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When active correction cannot |
by hyper-dorsiflexing the great toe |
tine investigations need to be ordered |
alised inflammatory conditions , then |
tation of the tarsal bones in |
PAGE 40 |