Foot Problems in Children

Ovid: Staying Out of Trouble in Pediatric Orthopaedics

Authors: Skaggs, David L.; Flynn, John M.
Title: Staying Out of Trouble in Pediatric Orthopaedics, 1st Edition
> Table of Contents > Section 5 – Lower Extremity > 25 – Foot Problems in Children

Foot Problems in Children
David L. Skaggs
John M. Flynn
Vincent S. Mosca
Kenneth Noonan
Guest Guru



How some parents seem to see their children
Adapted from Wenger DR, Rang M, eds. The Art and Practice of Children’s Orthopaedics. New York: Raven Press, 1993.
Flatfoot is the normal and expected foot shape in
infants, due in part to excessive subcutaneous fat, but also due to
true valgus alignment of the bones and joints. As part of development,
the longitudinal arch of the foot becomes more pronounced and the fat
disappears. Flatfoot is present in 23% of adults, and is usually
asymptomatic.1 The key to staying
out of trouble with this condition is in recognizing that the flatfoot
is a normal foot shape in most affected children and adults (Fig. 25-1).
It is also important to differentiate flexible flat feet from
pathologic flat feet. This is accomplished by observing the appearance
of an arch when a flatfooted child stands up on the toes, or is
non-weight bearing with the foot dangling in the air. It is also
vitally important to verify hindfoot motion, which can also be done by
observing the child rising up to stand on the toes, as the flexible
hindfoot will move from a valgus to varus position (Fig. 25-2).
Hindfoot mobility can also be assessed by cupping the heel in the
examiner’s hand and shifting from side to side (inverting and everting)
(Fig. 25-3).
FIGURE 25-1 (A) In normal weight-bearing position, this patient has a very flat foot. (B) When standing on his toes, the arch is visible. This dynamic change with foot position defines a flexible flatfoot.
If the arch does not elevate when the child is up on the
toes, or the hindfoot is not mobile, the child does not have a flexible
flat foot. Causes of rigid flatfoot include tarsal coalition, vertical
talus, neuromuscular condition, inflammatory arthritis, infection, etc.
An easily overlooked part of flatfoot assessment is contracture of the
Achilles tendon. This can be evaluated by passively dorsiflexing the
ankle while holding the subtalar joint in a neutral-to-slight varus
position, with the knee in full extension. If, when tested in this
manner, at least ten degrees of ankle


is not possible, the child will frequently complain of pain under the
medial midfoot. A painful flatfoot with a tight Achilles tendon
warrants treatment.

FIGURE 25-2 (A) Patient with flatfeet and hindfoot valgus. (B)
When standing on the toes, the hindfoot goes into varus, proving the
hindfoot is mobile, and the arch elevates, thus confirming a flexible
Once an asymptomatic, flexible flatfoot has been
diagnosed, share with the parents that this is not a problem, but a
normal variation. It may be helpful to share with parents that studies
of both military recruits and grocery store employees who are on their
feet much of the day found that flexible flatfeet are not a source of
disability in adults.1,2 It has been shown that wearing corrective shoes or inserts does not influence the course of flexible flatfoot in children.3
Furthermore, wearing shoe modifications during childhood has been shown
to be a negative experience and associated with lower self-esteem in
adult life.4 While not prescribing “something” may get you in trouble with the parents, above all we must do not harm to the child.
FIGURE 25-3 Hindfoot mobility can be assessed by cupping the heel and shifting it from side to side (inverting and everting).
It does not seem surprising that placing a hard object
under an already flat foot may cause discomfort, particularly in those
with an Achilles tendon contracture. Children who have undergone
orthotic-ectomies with complete relief of pain and guilt are among our
most grateful patients.
An entirely different universe is the symptomatic
flatfoot. We should treat symptoms, not deformity. Painful flexible
flatfeet may be associated with an accessory navicular, tight heel
cords, or other conditions. It is essential that foot radiographs are
taken with the child bearing weight (Fig. 25-4), and be aware that


many of the radiographs patients bring with them will not be.
Over-the-counter soft shoe inserts, available at many sporting good
stores, will often relieve symptoms of diffuse foot aching. Consider
surgery only as the last resort. Avoid fusions, as the calcaneal
lengthening osteotomy has good results and preserves subtalar motion.5
Synthetic implants have been used frequently by non-physician
healthcare providers, and we have seen disasters. We recommend staying
away from implants until they have been shown to be equal in safety and
efficacy to the calcaneal lengthening osteotomy.

FIGURE 25-4 (A) Non-weight bearing AP radiograph of the foot demonstrates reasonable alignment of the talonavicular joint (arrow). (B)
Weight-bearing view of the same child’s foot taken moments later
demonstrates medial subluxation of the talar head relative to the
navicular (arrow).
Accessory bones of the foot are often discovered on
radiographs for minor trauma, and are mistaken for fractures. Remember
that more than 20% of children have at least one accessory bone that
can be seen on radiographs.9

The Accessory Navicular
Many feel that nearly all children and adolescents who
have a symptomatic accessory navicular become asymptomatic when they
reach skeletal maturity, suggesting that surgery should be delayed and
used only as a last resort. Use of a medial longitudinal arch support
may exacerbate the symptoms by adding more pressure to the region,
whereas a UCBL (University of California Biomechanics Laboratory) shoe
insert may unweight the painful area by bringing the heel into varus
and elevating the arch of the foot. Surgical excision of the accessory
navicular without re-routing of the posterior tibial tendon has been
reported to have good results.10 However, any surgery in a painful weight-bearing region of the foot is prone to continued discomfort (Fig. 25-5).
FIGURE 25-5 Accessory navicular (arrow).
The Os Trigonum
The os trigonum is a normal variant present in 13% of
children, where the flexor hallucis longus passes in the groove along
the posterior talus. The trouble with this accessory bone is that it
can fracture and cause pain or become symptomatic in ballet dancers
presumably due to prolonged weight bearing in equinus. A fractured os
trigonum may have a rough or sharp border along the talus, in contrast
to an unfused os trigonum with a smooth border (Fig. 25-6).
FIGURE 25-6 Os trigonum (arrow). Note that the edges are smooth, suggesting that this is not a fracture.

Apophysis at Base of Fifth Metatarsal
Although not really an accessory bone, the apophysis at
the base of the fifth metatarsal where the peroneus brevis attaches is
often confused with a fracture by the unknowing (Fig. 25-7).
AP radiograph of a child’s foot demonstrating the normal apophysis of
the fifth metatarsal where the peroneus brevis tendon attaches (white arrow),
which is more or less parallel to the long axis of the metatarsal. This
normal apophysis is not to be confused with a fracture of the proximal
fifth metatarsal (black arrow), which tends to occur perpendicular to the long axis of the metatarsal.
While an entire book can be written on clubfoot, we will
just stick to a limited number of pitfalls. Clubfoot is frequently part
of an underlying syndrome, thus a complete history and physical is
warranted to uncover other abnormalities. Clubfoot is also associated
with tarsal coalition11 and fibular hemimelia.12
There is no indication for pelvis radiographs, as there is no known association between clubfoot and DDH.13
All children being evaluated for musculoskeletal problems should have a
careful hip exam. Imaging of hips should be based purely on risk
factors or findings suggestive of DDH.
It is hard to get in trouble with this condition as long
as you make the right diagnosis and don’t treat it. First, make certain
there is normal ankle dorsiflexion; if not, it is not metatarsus adductus (MTA), and may be a clubfoot. Look at the hindfoot; if there is significant valgus, think of a skewfoot (Fig. 25-10).
It may be difficult to differentiate between MTA and skewfoot with
radiographs in infants as the navicular is not yet ossified (Fig. 25-11). MTA may also be confused with a metatarsal longitudinal epiphyseal bracket (Fig. 25-12).
FIGURE 25-10 (A) At first glance, this child may appear to have severe metatarsus adductus. (B)
When viewed from behind, the significant heel valgus (which does not
correct when standing on his toes) suggests something other than
metatarsus adductus. This child has a skewfoot.
FIGURE 25-11 (A) AP radiograph of a 1-year-old. Is this metatarsus adductus? (B) AP radiograph of the same foot, at age 4 years. Note that the navicular is now ossified (arrow)
and can be appreciated in its position far lateral to the center of the
talar head, making the diagnosis of skewfoot easier to appreciate.

FIGURE 25-12 (A)
This child has a metatarsal bracket of the left foot. An increased
space between the first and second toes is a clue that this foot has
something other than metatarsus adductus. (B) AP radiograph demonstrating the longitudinal epiphyseal bracket (arrows) of the first metatarsus in this child.
In the extraordinarily unlikely event that surgery is
needed for MTA, do not do a capsular release as this leads to poor
results. We recommend an osteotomy of the medial cuneiform, rather than
the first metatarsal, both to avoid the proximal physis of the first
metatarsal, and for better correction. Lateral osteotomies may be of
the second to fifth metatarsals or the cuboid.
First off, forget about the foot and look for an
underlying neurologic condition. It has been reported that two thirds
of patients with painful high arches have an underlying neurologic
problem that turns out to be Charcot-Marie-Tooth about 50% of the time.23
If there are bilateral cavus feet, think of neuromuscular disease. If
the occurrence is unilateral, think of a spinal problem and order an
MRI of the entire spine. As a spine examination is not complete without
inspection of the feet, examination of a child with a cavus foot is not
complete without inspection of the spine. If the underlying
neuromuscular problem is treatable, get on with it before treating the
foot. Treatment for progressive cavus deformity with pain and
instability is surgical. Make certain the parents understand that the
foot deformity is not the problem, but is the result of the problem. It
is possible that future surgery will be needed, as the underlying
disease progresses in many cases.

This is an uncommon condition that is commonly
associated with underlying neuromuscular conditions or syndromes. The
surgeon’s first job is to identify those other conditions.
In the young infant, this deformity may not be quite as
obvious as some other foot deformities. A prominent talar head in the
setting of a rigid foot is suspicious, but avoid confusing an oblique
talus, positional calcaneovalgus, posteromedial bowing of the tibia, or
just a really flat foot, with a vertical talus (Fig. 25-13A).
By definition, a vertical talus is a fixed dorsal dislocation of the
navicular on the head of the talus. As the navicular is not ossified
until about age 3 years, and cannot be seen on plain radiographs, we
rely on the relationship of the axis of the talus and the first
metatarsal. The diagnosis is confirmed on the plantar flexed lateral
radiograph by observing that the axis of the talus passes plantar to
that of the first metatarsal (Figs. 25-13B and C).
Avoid the pitfall of believing that if the two axes become parallel,
there is not a vertical talus. Dorsal translation of the first
metatarsal axis in relation to that of the talus indicates dorsal
dislocation at the talonavicular joint (Fig. 25-14). The axis of the talus remains vertically aligned with the axis of the tibia on the dorsiflexion lateral radiograph.
FIGURE 25-13 Three-month-old with vertical talus. (A) Rocker bottom medial prominence characteristic of vertical talus. (B)
Lateral radiograph of foot is nondiagnostic. Although the axis of the
talus is plantar to that of the first metatarsal, this radiograph is
consistent with an oblique talus as well as vertical talus. (C)
A forced plantarflexion lateral radiograph confirms the diagnosis of
vertical talus as the axis of the talus and first metatarsal still do
not line up, and the talus remains quite vertical relative to the first
Unlike clubfoot, casting is generally considered
unlikely to correct the vertical talus deformity, though Dr. Matthew
Dobbs in St. Louis has reported some success.


Preoperative plantar flexion casting will stretch the dorsal skin and tendons, thus facilitating surgical deformity correction.

FIGURE 25-14 Example of a child with vertical talus (A) in which the axes of the talus and first metatarsal become nearly parallel in plantar flexion (B),
but the axis of the first metatarsal is translated dorsal to that of
the talus. Recall that the definition of a vertical talus is a fixed,
dorsal dislocation of the navicular relative to the talus to help
understand why this radiograph is consistent with a vertical talus.
FIGURE 25-15 (A)
Child with an oblique talus. Note that this radiograph shows a quite
similar relationship between the talus and first metatarsal as that
seen in Fig. 25-14. (B) With plantar flexion, the axis of the talus and first metatarsal significantly change their relationship.
Many series report a higher recurrence rate following
bunion surgery in adolescents than in adults. Stay out of trouble by
delaying surgery until skeletal maturity, if possible. If surgery is
needed, consider an opening wedge osteotomy of the medial cuneiform, if
the intermetatarsal angle is greater than 8 degrees. This will help
correct a medially deviated cuneiform-first metatarsal joint, as well
as avoid potential damage to the first metatarsal growth plate.
The first pitfall is making the correct diagnosis. The
diagnosis of a tarsal coalition should be strongly suspected from the
physical examination, based on decreased subtalar joint motion and
inability to voluntarily invert the foot (see Fig. 25-3). Many children with a tarsal coalition present with rigid heel valgus and tightness of the peroneal tendons (Fig. 25-16).
Standard AP and lateral radiographs may not always
clearly demonstrate tarsal coalitions, but they do provide lots of
clues. Oblique views are usually diagnostic of a calcaneonavicular
coalition, (Fig. 25-17) though a fibrous
coalition is best visualized on an MRI. A talocalcaneal coalition may
be seen on a Harris view if you are lucky enough to get a perfect shot,
but is most reliably seen on a CT scan (Figs. 25-17 and 25-18).
A recent series of 48 patients found the C-sign of Lateur on the
lateral radiograph to be present in all patients with flatfeet, but
present in only 40% of those with tarsal coalitions,24 (Fig. 25-18)
so an absence of the C-sign does not rule out a tarsal coalition. A CT
scan should be considered for all feet in which a calcaneonavicular
coalition has been identified on plain radiographs because of the
possibility of a coincidental talocalcaneal coalition in the same foot.
A second coalition was identified in 20% of patients undergoing CT
scans for tarsal coalition at the Texas Scottish Rite Hospital, though
this population from a tertiary pediatric center may be skewed towards
more severe cases.25

FIGURE 25-16
Photo of one of the authors sitting next to a patient with frequent
recurrent ankle sprains. Both are trying to invert their feet, but the
patient cannot due to bilateral tarsal coalitions.
FIGURE 25-17 (A)
On a lateral radiograph of the foot, a calcaneonavicular coalition is
difficult to identify conclusively. The arrow points to an elongated
anterior process of the calcaneus (“anteater” sign), which is
suggestive of a calcaneonavicular coalition. (B) The contralateral normal foot for comparison. (C) An oblique view clearly demonstrates the calcaneonavicular bar (arrow). (D) The contralateral normal foot for comparison demonstrates no coalition (arrow).

FIGURE 25-18 Talar calcaneal bar is difficult to appreciate on plain radiographs, however talar beaking (white arrow) and the C-sign (black arrows) suggest this coalition may be present.
The majority of children and adults with tarsal
coalitions are asymptomatic, so the second pitfall here is in treating
something that doesn’t need treatment. Pain onset is usually between
ages 8 and 16 years in those who become symptomatic. The exact site(s)
and source(s) of pain in tarsal coalitions are not well established. A
few weeks of immobilization in a cast or walking boot may get a child
through a symptomatic period, and save the child from surgery.
Unfortunately, it is our experience that in most children who present
with painful tarsal coalitions, pain will return after immobilization,
and surgery is likely eventually.
At the time of surgery, be aware of how many coalitions
exist in the foot and have a plan for your approach to each. Recurrent
discomfort occurs at times due to inadequate resection, particularly of
the talocalcaneal coalitions. Make certain that adequate bone is
removed at the primary surgery so that normal cartilage and joint is
seen at the periphery of the resection, and full inversion of the heel
does not cause impingement at the region of resection. Last, but not
least, as with any operation to treat pain in the feet, make the
patient and family aware that pain relief cannot be guaranteed.
This is a very common deformity in newborns. Although
the appearance of the foot may be striking, spontaneous correction is
the rule (Fig. 25-19). Having the parents
perform stretching exercises may help the babies, and will keep the
parents happy that something is being done. The thing to watch out for,
on tests more than in real life, is the true diagnosis of posterior
medial bowing of the tibia, which usually corrects spontaneously but
may result in a 3- to 4-cm leg length discrepancy. See Chapter 10 on newborns for more discussion of this subject.
FIGURE 25-19 Calcaneal valgus in a newborn. It is not unusual for the dorsum of the foot to be touching the leg anterior to the tibia.
This condition is no trouble as long as you recognize it
and do not confuse it with infection, fracture, or something more
serious. Do not treat if there are no symptoms, but immobilization for
a few weeks should help relieve discomfort.


Multiple ossification centers of the navicular may be confused with Köhler disease (Fig. 25-20).

FIGURE 25-20 Lateral view of a child with foot pain demonstrates Köhler disease. Arrow points to collapsed, avascular navicular.
Polydactyly is common and usually an isolated finding,
although it can be associated with Ellis-Van Creveld syndrome, Down
syndrome and tibial hemimelia. Thus you should be on the lookout for
underlying disorders when encountering polydactyly.
In contrast, absent toes may signify an underlying
longitudinal deficiency, most commonly fibular hemimelia, and may be
associated with other conditions such as a leg length discrepancy, ball
and socket ankle, or absent ACL.
FIGURE 25-21 (A)
AP radiograph of a foot with preaxial duplication in a 1-month-old. The
abnormally shaped first MT is characteristic of a longitudinal
epiphyseal bracket. (B) An MRI of the same foot at age 7 months demonstrates the cartilage (black arrows)
wrapping around the first MT, confirming the diagnosis or a
longitudinal epiphyseal bracket. The proximal phalange of each of the
two great toes is shown by white arrows.

Syndactyly of the toes is rarely symptomatic, and can be
made much worse with surgery. Excessive scarring and unhappiness with
cosmetic appearance is not uncommon following surgical resection. But
don’t worry, plastic surgeons don’t read this book, so you may refer
patients who demand surgery to them.

1. Harris R, Beath T. Army Foot Survey: An Investigation of Foot Ailments in Canadian Soldiers. Ottawa, National Research Council of Canada, 1947.
2. Hogan MT, Staheli LT. Arch height and lower limb pain: an adult civilian study. Foot Ankle Int. 2002;23(1):43-47.
3. Wenger
DR, Mauldin D, Speck G, et al. Corrective shoes and inserts as
treatment for flexible flatfoot in infants and children [see comment]. J Bone Joint Surg Am. 1989;71(6):800-810.
4. Driano AN, Staheli LT. Psychosocial development and corrective shoewear use in childhood. J Pediatr Orthop. 1998;18(3):346-349.
5. Mosca
VS. Calcaneal lengthening for valgus deformity of the hindfoot: results
in children who had severe, symptomatic flatfoot and skewfoot. J Bone Joint Surg Am. 1995;77(4):500-512.
6. Seymour N. The late results of naviculo-cuneiform fusion. J Bone Joint Surg Br. 1967;49(3): 558-559.
7. Angus PD, Cowell HR. Triple arthrodesis. A critical long-term review. J Bone Joint Surg Br. 1986; 68(2):260-265.
8. Tenuta J, Shelton YA, Miller F. Long-term follow-up of triple arthrodesis in patients with cerebral palsy. J Pediatr Orthop. 1993;13(6):713-716.
9. Shands A. The accessory bones of the foot. Soth Med Surg. 1931;9:326.
10. Bennett GL, Weiner DS, Leighley B. Surgical treatment of symptomatic accessory tarsal navicular. J Pediatr Orthop. 1990;10(4):445-449.
11. Spero CR, Simon GS, Tornetta P III. Clubfeet and tarsal coalition. J Pediatr Orthop. 1994; 14(3):372-376.
12. Caskey PM, Lester EL. Association of fibular hemimelia and clubfoot. J Pediatr Orthop. 2002;22(4):522-525.
13. Westberry
DE, Davids JR, Pugh LI. Clubfoot and developmental dysplasia of the
hip: value of screening hip radiographs in children with clubfoot. J Pediatr Orthop. 2003;23(4):503-507.
14. Morcuende
JA, Dolan LA, Dietz FR, et al. Radial reduction in the rate of
extensive corrective surgery for clubfoot using the Ponseti method. Pediatrics. 2004;113(2):376-380.
15. Ponseti IV. Congenital Clubfoot: Fundamentals of Treatment. Oxford, England: Oxford University Press; 1996.
16. Kite JH. Principles involved in the treatment of congenital club-foot. J Bone Joint Surg Am. 1939; 21:595-606.
17. Dobbs
MB, Gordon JE, Walton T, et al. Bleeding complications following
percutaneous tendoachilles tenotomy in the treatment of clubfoot
deformity. J Pediatr Orthop. 2004;24(4):353-357.
18. Dobbs
MB, Rudzki JR, Purcell DB, et al. Factors predictive of outcome after
use of the Ponseti method for the treatment of idiopathic clubfeet. J Bone Joint Surg Am. 2004;86A(1):22-27.
19. Dobbs MB, Gordon JE, Schoenecker PL. Absent posterior tibial artery associated with idiopathic clubfoot. A report of two cases. J Bone Joint Surg Am. 2004;86(3):599-602.
20. Kuo KN, Jansen LD. Rotatory dorsal subluxation of the navicular: a complication of clubfoot surgery. J Pediatr Orthop. 1998;18(6):770-774.
21. Stevens PM, Otis S. Ankle valgus and clubfeet. J Pediatr Orthop. 1999;19(4):515-517.
22. Rogers JG, Geho WB. Fibrodysplasia ossificans progressiva: a survey of forty-two cases. J Bone Joint Surg Am. 1979;61(6A):909-914.
23. Brewerton D, Sandifer P, Sweetnam DR. “Idiopathic” pes cavus: an investigation into its aetiology. Br Med J. 1963;2:659-661.
24. Brown RR, Rosenberg ZS, Thornhill BA. The C sign: more specific for flatfoot deformity than subtalar coalition. Skeletal Radiol. 2001;30(2):84-87.
25. Clarke, PM. Multiple tarsal coalitions in the same foot. J Pediatr Orthop. 1997;17(6):777-780.
DA, Albanese EL, Levinsohn EM, Hootnick DR, et al. Pulsed color-flow
Doppler analysis of arterial deficiency in idiopathic clubfoot. J Pediatr Orthop. 2003;23(1):84-87.
Mosca VS. The cavus foot. J Pediatr Orthop. 2001;21(4):423-424.
Mosca VS. The child’s foot: principles of management. J Pediatr Orthop. 1998;18(3):281-282.

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