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Updated: Nov 2 2021

Flexible Pes Planovalgus (Flexible Flatfoot)

Images photo - flexible flatfoot - courtesy Miller_moved.png flex flatfoot normal mearys angle_moved.jpg
  • summary
    • Flexible Pes Planovalgus, also known as Flexible Flatfoot, is a common idiopathic condition, caused by ligamentous laxity that presents with a decrease in the medial longitudinal arch, a valgus hindfoot and forefoot abduction with weight-bearing.
    • Diagnosis can be made clinically with a foot that is flat with standing and reconstitutes with toe walking, hallux dorsiflexion, or foot hanging.
    • Treatment is usually observation, and stretching with majority of cases resolving over time. Rarely, surgical management is indicated for patients with progressive deformities that do not resolve with nonoperative management. 
  • Epidemiology
    • Incidence
      • unknown in pediatric population
      • 20% to 25% in adults
  • Etiology
    • Pathoanatomy
      • generalized ligamentous laxity is common
      • 25% are associated with gastrocnemius-soleus contracture
  • Classification
    • 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
  • Presentation
    • 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
  • Imaging
    • Radiographs
      • indications
        • painful flexible flatfoot to rule out other mimicking conditions
        • 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 (where a line through the long axis of the talus passes below 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
  • Differential
    • Tarsal coalition
    • Congenital vertical talus
    • Accessory navicular
  • Treatment
    • 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
  • Prognosis
    • Most of the time resolves spontaneously
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