HOW TO TREAT 43 hypermobile flat foot are two conditions that serve to create in-toeing and out-toeing respectively . Metatarsus adductus consists of medial deviation of the forefoot with a neutral or slightly valgus heel
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HOW TO TREAT 43 hypermobile flat foot are two conditions that serve to create in-toeing and out-toeing respectively . Metatarsus adductus consists of medial deviation of the forefoot with a neutral or slightly valgus heel
It is extremely common , with one in 5000 live births and one in 20 siblings presenting with the condition . 10 The incidence is higher in males , twin births and preterm deliveries . Early studies correlated this condition with hip dysplasia , but more recent studies suggest this correlation does not exist . 10
The condition is seen mostly in the first year of life , can be unilateral and , like the other conditions discussed in this article , is mostly self-resolving . The key to screening for patients who may need early referral is the flexibility of the deformity . When the forefoot deformity can be corrected to the midline or beyond , the likelihood of spontaneous resolution is high , with studies indicating that , even in cases where mild deformity persists into adulthood , there is low to no incidence of associated pain . 10
The presence of metatarsus adductus and its severity can be determined by examination of the sole of the foot . This can be achieved by examining the patient in the same position as the previous two elements : lying prone , thighs flat on the exam table and knees bent to 90 °. This position affords the examiner an excellent view of the soles of both feet . The heel bisector line is drawn along the long axis of the midfoot , and the diagnosis can be made when this line crosses the forefoot lateral to the 2 / 3 webspace ( mild ); bisection of the third metatarsal is classified as moderate , and lateral to this is severe .
1 . Which THREE statements regarding paediatric foot and ankle deformity are correct ? a Parents are often concerned about the long-lasting implications of deformity on the normal development of gait . b All paediatric foot and ankle deformities require surgical intervention . c The most common presentations are flat feet and in-toeing and out-toeing during gait . d More serious diseases may mimic benign presentations .
2 . Which THREE not-to-be-missed conditions may mimic flat foot ? a Tibial torsion . b Tarsal coalition . c Accessory navicular . d Congenital vertical talus .
3 . Which TWO are red flags in a paediatric flat foot ? a Family history of flat foot . b Pain that requires analgesia for relief . c Previously normal appearance with new-onset deformity . d Signs / symptoms consistent
Figure 10 . Transmalleolar axis .
Investigation
Investigations for in- and out-toeing are typically unnecessary and are generally reserved only for those with red-flag symptoms
How to Treat Quiz .
concerning for conditions that may require surgical referral , review and management .
Plain X-rays of the hips , feet and ankles will typically screen
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with neurological or inflammatory causes .
4 . Which THREE are relevant in the evaluation of a flat foot ? a Asking older children to walk on their heels to see if the medial longitudinal arch reconstitutes . b A general inspection of the whole patient . c Watching the patient walk . d A neurological examination of reflexes and power if there are concerns about a neuromuscular or spinal cause for the deformity .
5 . Which ONE is an indication for referral of a child with a flat foot ? a Parental concern . b The presence of red flags . c A child who has obesity . d Flat foot persisting in adolescence .
6 . Which THREE conditions must not be missed in a patient with in- or out-toeing ? a Developmental dysplasia of the hips . b Skeletal dysplasias . c Slower-than-average running speeds . d Neuromuscular disorders .
7 . From which THREE anatomical sites may in- or out-toeing arise ? a Hips . b Feet . c Tibiae . d Knees .
8 . Which ONE is not a risk factor for developmental dysplasia of the hips ? a Large for gestational age . b Unequal limb lengths . c Maternal obesity . d Family history .
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PAEDIATRIC FOOT AND ANKLE DEFORMITY
for underlying dysplasia and rule out any overt bony or morphological cause . As with flat feet , features concerning for a neurological cause may require an MRI of the patient ’ s neural axis and appropriate referral .
CASE STUDIES
Case study one
JOHN , four , is brought in by his parents , who are concerned about an abnormal gait and flat feet . They first noticed John ’ s feet were flat after a relative made a comment at a family function .
The child has not complained of any pain and has participated in active play with his friends without restriction . He has had an otherwise unremarkable childhood , reaching all milestones without notable incident .
On examination , he is a bright , reactive child . John walks with both feet slightly externally rotated , and his medial arch is obliterated ; this is symmetrical . During toe-off and when asked to stand on his tiptoes , his hindfoot is noted to swing back into varus alignment and his medial arch recreates . These findings are confirmed with passive manipulation .
A plain film X-ray is ordered and shows no abnormal bony or joint morphology . In the absence of any red-flag signs or symptoms and with normal imaging , the GP offers reassurance that this deformity does not need any active treatment and that only supportive footwear and activity are required .
Over the next few years , John continues to be active , participating in sporting activities without concern . His parents note that his feet still look flat while he is standing but have improved over
9 . Which THREE statements regarding in- and out-toeing are correct ? a Most cases of rotational deformity present with outrather than in-toeing . b Patients are likely to present once they have started walking . c Determine a complete rotational profile in any child who presents with concerns about excessive internal or external foot progression angle . d Femoral anteversion is the most common cause of intoeing in early childhood .
10 . Which THREE statements regarding in- and out-toeing are correct ? a Out-toeing is likely to improve with age . b The presence of in-toeing has been shown to improve sprinting ability . c Metatarsus adductus and hypermobile flat foot are mainly self-resolving . d Investigations are typically unnecessary and generally reserved for those with red flags . time , and they are happy with the outcome .
Case study two
Jane , five , presents after complaining to her parents that she experiences knee pain after sport . The pain is intermittent and is relieved with rest . Unfortunately , it has limited her desire to participate in school and local sporting activities . Her parents do not recall any recent illness , previous episodes of longstanding pain or other joint involvement . There are no red-flag features in the history for inflammatory or post-traumatic pathology . Her parents mention she has had a recent growth spurt . Her teachers have also noted that she likes to ‘ W ’ sit in class .
On examination , her gait reveals bilateral symmetrical in-toeing . Her patellae point inward on coronal inspection . A cursory hip and knee exam are unremarkable . Rotational profile examination reveals internal hip rotation of 90 ° and external rotation of 20 °. Her TFA and transmalleolar axis are within normal limits , as is her heel bisector .
A cursory screening X-ray of her hips shows well-formed proximal femora and normal acetabular indices . X-rays of her knees are unremarkable for pathology .
Based on these findings , her GP is happy that this femoral anteversion is the cause of her in-toeing gait and that this , in combination with her recent growth spurt , is contributing to her current presentation .
The parents are reassured there is no sinister pathology and that , with supportive measures — like simple analgesia , appropriate periods of rest , stretching and activity modification — her pain should improve with time , as should the in-toeing gait .
CONCLUSION
FLAT foot is a typically benign and self-resolving entity . The spectrum of normal is broad , and the likelihood that surgical input will be necessary is very low .
The role of the GP is to ensure the diagnosis is benign and to reassure family members and patients alike ; the judicious use of non-surgical adjuncts , such as physiotherapy and podiatry , are useful tools to help the family feel they are doing something to ‘ fix the problem ’.
As with flat feet , in- / out-toeing deformities are typically on a broad spectrum of normal and require no intervention or treatment for complete resolution . Cursory screening for causes not to be missed is essential . Further investigation and early referral are necessary in any cases of concern or in those with an equivocal diagnosis .
RESOURCES
The Royal Children ’ s Hospital Melbourne — Flat feet bit . ly / 3P5mBJR — Out-toeing bit . ly / 3Pb2Ro8 — In-toeing bit . ly / 3XSpwcC
References Available on request from howtotreat @ adg . com . au