Updated: 4/17/2018

Flexible Pes Planovalgus (Flexible Flatfoot)

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Introduction
  • Physiologic variant consisting of a decrease in the medial longitudinal arch and a valgus hindfoot and forefoot abduction with weightbearing
  • Epidemiology
    • incidence
      • unknown in pediatric population
      • 20% to 25% in adults
  • Pathoanatomy
    • generalized ligamentous laxity is common
    • 25% are associated with gastrocnemius-soleus contracture
  • Prognosis
    • most of the time resolves spontaneously
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
        • tarsal coalition (sinus tarsi pain)
        • congenital vertical talus (rocker bottom foot)
        • accessory navicular (focal pain at navicular)
      • 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 with a line through the long axis of the talus passing above 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
Techniques
 
Complications
 
 

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Questions (5)
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(OBQ10.13) The Evans lateral calcaneal lengthening osteotomy is the surgical procedure most appropriate for which pediatric foot deformity? Review Topic

QID: 3101
1

Talipes equinovarus

10%

(173/1778)

2

Cavus foot

15%

(263/1778)

3

Flexible pes planovalgus

70%

(1248/1778)

4

Juvenile hallux valgus

1%

(22/1778)

5

Kohler's disease

3%

(59/1778)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ10.232) A 12-year-old boy has 2 years of right foot pain that prevent participation in athletic activities and is symptomatic with walking. He has attempted UCBL and custom made orthoses for 1 year with no relief of symptoms. His hindfoot is supple and he has full dorsiflexion. Clinical images of the foot are shown in Figures A and B. A lateral radiograph is shown in Figure C. A surgical plan to address the deformity would most appropriately include which of the following? Review Topic

QID: 3331
FIGURES:
1

Lateral calcaneal slide osteotomy

19%

(383/2062)

2

Transfer of the peroneus longus to the peroneus brevis

6%

(126/2062)

3

1st metatarsal dorsiflexion osteotomy

9%

(187/2062)

4

Calcaneal neck lengthening osteotomy

53%

(1083/2062)

5

Posterior tibial tendon transfer to dorsum of the foot

13%

(265/2062)

ML 4

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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