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Lecturer: Craig Payne

This lecture covers:

* Talipes deformities (clubfoot)

* Pes planus (flat feet)

* Congenital vertical talus

* Pes cavus

* Tarsal coalitions

Talipes deformities/Clubfoot

4 types:- Talipes equinovarus, talipes equinovalgus, talipes calcaneovarus, talipes calcaneovalgus

Clubfoot – generally used to describe the most common (talipes equinovarus) – characterised by forefoot adduction with a varus and equinus rearfoot.

Talipes Equinovarus

1 to 2 per 1000 live births. 50% are bilateral. M>F.

Aetiology:
Cause unknown (or controversial), but resemble the foetal foot at about the 7th to 9th week. Associated with a number of diseases (eg spina bifada, myelomeningocele, congenital hip dislocation), but most are idiopathic. Almost all diagnosed at birth.

Classification:
1) Idiopathic/congenital
2) Positional (deformed by in-utero pressure; can be easily reduced; prognosis better than idiopathic)
3) Teratologic (has other deformities (eg congenital hip dysplasia); more severe with poor prognosis)
4) Syndrome (genetic; part of a syndrome; eg Larsen syndrome )

Pathological anatomy:
Adducted forefoot; inverted hindfoot; ankle equinus; plantar medial displacement of the navicular on the head of the talus; lateral rotation of the body of the talus in the ankle mortise; posterior deviation of the lateral malleolus; medial subluxation of cuboid on the calcaneus; soft tissue contractures; calf muscles are atrophied; anterior tibial blood vessel anomalies are common;

Clinical features:
Plantarflexed and inverted position of foot; medial malleolus abuts navicular; talus head is prominent dorsolaterally; forefoot is adducted; variable rigidity; mild calf atrophy; radiographic changes (measurements difficult due to small size of ossification centres).

Treatment:
Early recognition is important for better prognosis.
Initially manipulation and casting – later surgical.

Long term sequelae:
Sign of surgical correction – creasing plantar and medial to talonavicular area.
Rocker bottom foot – occurs when surgical correction dorsiflexes forefoot on rearfoot rather than at ankle.
Flat top talus – range of ankle joint motion is decreased
Navicular wedging – due to compressive forces used to correct clubfoot.

Talipes Equinovalgus

Rare. Associated with conditions such as arthrogryposis multiplex congenita. Foot is everted and plantarflexed.

Talipes Calcaneovarus

Rare. Entire foot is dorsiflexed and inverted.

Talipes Calcaneovalgus

Up to 1% of live births – most resolve spontaneously (mild form may be in up to 30-50% of normal births). Foot is in exaggerated position of dorsiflexion - valgus force at STJ ? calcaneus in valgus position and forefoot abducted. Dorsal aspect of foot is in contact with anterior tibia – typically is flexible (congenital vertical talus is not). Probably due to abnormal intrauterine position. Prognosis is excellent and spontaneously reduces when weightbearing occurs. Occasionally serial casting needed.

Online resources:

ePodiatry's resources on clubfoot and talipes and parent information on clubfoot

Clubfoot - online article from eMedicine

(Revise your second year biomechanics)

Literature is confusing regarding terminology. Many cases are part of normal development – young children tend to have fat pad in arch giving appearance of flat foot.

Causes of abnormally flat or pronated feet in children:
Congenital vertical talus
Abnormal insertion of posterior tibial tendon
Posterior tibial dysfunction
Forefoot varus
Equinus
Peroneal spastic flatfoot
Medially located STJ or rearfoot axis
Ligamentous laxity
Torsional disorder of lower limb
Idiopathic

Classification
• clinical appearance
• aetiology
• plane of compensation

Considerable debate in literature as to natural history and the need to intervene if asymptomatic - ethical decision to intervene in consultation with parents. (Podiatry Arena discussion on: Foot orthoses and asymptomatic pediatric flatfoot )

General guidelines - treat if subtalar joint is pronated after heel off; symptomatic; severe; significant medial column collapse; significant transverse plane motion; history of symptomatic problems in parents

Treatment options:
Shoe modifications – Thomas heels; rigid heel counters; heel raise; medial heel flare; move heel medially
In-shoe modifications – heel wedges; arch cookies; triplane wedges
Foot orthoses – prefabricated orthoses, functional; inverted devices; high medial flange devices; gait plates; UCBL; prefabricated
Adjunct therapy – stretching (especially if <10º at ankle); muscle strengthening
Surgical -

Congenital vertical talus

Rare. Dorsal dislocation of navicular on talus (may be a form of clubfoot).

Cause unknown – but intrauterine position, genetic and neuromuscular conditions have been implicated. May be isolated deformity of part of another syndrome (eg arthrogryposis multiplex congenita; neurofibromatosis; nail-patella syndrome).

Rocker bottom appearance to foot; talus is prominent talus head in plantar medial side of foot; dorsal creasing in the MTJ region; rigid STJ; forefoot is abducted and dorsiflexed.
On x-ray, the dorsal dislocation of the navicular off the head of the talus onto the talar neck is seen

Posterior tibial tendon is more dorsally located ? acts as a dorsiflexor

Two types:
1. Dislocation of talonavicular joint, subluxation of subtalar joint, normal calcaneocuboid joint (more flexible)
2. Dislocation of talonavicular joint, subluxation of subtalar joint and calcaneocuboid joint, ankle joint equinus (more rigid)

Initially treatment at birth is manipulation and casting – later treatment is surgical. Prognosis is often not good without surgery.

Pes cavus/supinated foot

High arched foot. Literature is confusing regarding terminology.

Classification:
1. Anterior cavus
a) Total type – plantarflexion of entire forefoot (also called simple pes cavus)
b) Local type – plantarflexion of first ray (also called pes cavovarus)
2. Posterior type – high inclination of calcaneus in relation to talus (also called pes calcaneocavus)
3. Combination (global) – anterior and posterior – (also calcaneocavus deformity)

Can also be classified if it is flexible, semiflexible or rigid.

Up to half are idiopathic – rest have underlying neurological problem (eg Charcot-Marie-Tooth disease; poliomyelitis; Friedreichs ataxia). Most have a rigid plantarflexed first ray - supinatory force at subtalar joint (- cavus appearance) – amount of supination at subtalar joint will depend on ranges of motion of first ray and midtarsal joints.

Clinical features:
Exaggerated medial longitudinal arch; plantarflexion of forefoot on rearfoot; plantarflexed first ray; limited ankle joint dorsiflexion; tarsal ‘humping’; plantar hyperkeratosis; claw toes; inverted rearfoot; history of ankle sprains.

Classic x-ray features – high calcaneal inclination angle; high metatarsal declination angle; prominent sinus tarsi (the ‘bullet hole’ sign)

Treatment:
Investigate neuromuscular causes first
Conservative – foot orthoses (usually with forefoot valgus posting) and footwear accommodations
Surgical – soft tissue procedures (plantar fascia release, tendon release, tendon transfer); osteotomy (metatarsal, midfoot, calcaneus – depends on location of deformity); bone stabilisation procedures (eg triple arthrodesis)

Online resources:

ePodiatry's resources on flat feet

Congenital vertical talus - article from eMedicine

Congenital fibrous, cartilaginous or bony union between two or more tarsal bones. Considered to be a failure of differentiation or segmentation of primitive mesenchyme ? lack of complete joint formation. Most commonly medial talocalcaneal, calcaneonavicular, posterior talocalcaneal, talonavicular – can affect all tarsal bones. 50% are bilateral. Prevalence is unknown, but is assumed to be <1%.

Aetiology unknown – occur as an isolated problem or part of a syndrome (eg Apert’s syndrome);

Clinical features:
Depends on site, but as coalition ossifies ? becomes rigid and maybe painful ?peroneal spastic flat foot may develop. Pain/aches in region and decreased range of motion are most common features.
Usually becomes symptomatic around ages 8-12yrs for calcaneonavicular and 12-16yrs for talonavicular coalitions.

X-ray:
Most visible on x-ray – special views may need to be ordered. CT scans are helpful.
Secondary signs on x-ray:- talar beaking; narrowing of posterior talocalcaneal joint space; broadening or rounding of lateral process of talus; failure of visualisation of the middle facets of anterior STJ; elongation of anterior process of calcaneus

Treatment:
Pain relief – NSAID’s; activity restriction; strapping; physical therapy; achilles tendon/calf muscle stretching.
Short leg cast immobilisation for 6 weeks,
Orthoses to restrict motion – may need to hold foot in pronated position
Surgical resection of coalition is indicated if conservative treatment is unsuccessful and pain is persistent

Online resources:

ePodiatry's list of resources on tarsal coalitions

Lecture 1 ; Lecture 2 ; Lecture 3 ; Lecture 4; Lecture 6; Lecture 7; Lecture 8; Lecture 9; Lecture 10

Paediatrics lectures home page

Podiatric Specialisations home page

Medical Info Directory links on clubfoot