CLINICAL PRACTICE GUIDELINE
Diagnosis and Treatment
of Pediatric Flatfoot
Clinical Practice Guideline Pediatric Flatfoot Panel: Edwin J. Harris, DPM,1
John V. Vanore, DPM,2 James L. Thomas, DPM,3 Steven R. Kravitz, DPM,4
Stephen A. Mendelson, MD,5 Robert W. Mendicino, DPM,6
Stephen H. Silvani, DPM,7 and Susan Couture Gassen8
T his clinical practice guideline (CPG) is based on the con-
sensus of current clinical practice and review of the clinical
literature. The guideline was developed by the Clinical Practice
Guideline Pediatric Flatfoot Panel of the American College of
Foot and Ankle Surgeons. The guideline and references anno-
tate each node of the corresponding pathways.
Introduction to Pediatric Flatfoot (Pathway 1)
Foot and ankle specialists acknowledge that flatfoot de-
formity is a frequently encountered pathology in the pedi-
atric population. Flattening of the medial arch is a universal
finding in flatfoot and it is common in both pediatric and
adult populations. Pediatric flatfoot comprises a group of
conditions occurring in infants, children, and adolescents
(1) that are distinguished by anatomy and etiologic factors
(2, 3– 8).
Flatfoot may exist as an isolated pathology or as part of
a larger clinical entity (4). These entities include generalized
ligamentous laxity, neurologic and muscular abnormalities,
genetic conditions and syndromes, and collagen disorders.
Pediatric flatfoot can be divided into flexible and rigid
categories. Flexible flatfoot is characterized by a normal
arch during nonweightbearing and a flattening of the arch on
stance (Fig 1). Flexible flatfoot may be asymptomatic or
1
Chair, Pediatric Flatfoot Panel, Westchester, IL; 2Chair, Clinical Prac-
tice Guideline Core Committee, Gadsden, AL; 3Board Liaison, Birming-
ham, AL; 4Philadelphia, PA; 5Pittsburgh, PA; 6Pittsburgh, PA; 7Walnut
Creek, CA; 8Chicago, IL. Address correspondence to: John V. Vanore,
DPM, Gadsden Foot Clinic, 306 South 4th St, Gadsden, AL 35901. E-mail:
jvanore@bellsouth.net
Copyright © 2004 by the American College of Foot and Ankle Surgeons
1067-2516/04/4306-0002$30.00/0
doi:10.1053/j.jfas.2004.09.013
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004
symptomatic. Rigid flatfoot is characterized by a stiff, flat-
tened arch on and off weightbearing. Most rigid flatfeet are
associated with underlying pathology that requires special
consideration.
Skewfoot is an uncommon disorder characterized by se-
vere pronation of the rearfoot and an adductovarus forefoot.
Skewfoot has characteristics of flatfoot and adductovarus
deformity (8).
Significant History (Pathway 1, Node 1)
Pediatricians and parents often are the first to recognize
foot and ankle pathology in infants and children, but prob-
lems may go unrecognized for a long period of time. The
age of onset is important for diagnostic and therapeutic
decision making. Additional considerations include family
history, associated medical conditions, presence or absence
of symptoms, trauma history, activity level, previous treat-
ment, and a thorough review of systems.
Documented failure to improve, or a clinical worsening,
is contrary to the normal course and suggests that the
problem is more likely to persist with the possibility of
pathologic sequel. A family history of flatfoot suggests that
there may be similar issues in the child. Obesity, neuromus-
cular disorders, and structural abnormalities above the level
of the ankle (eg, ankle valgus, tibia varum, genu valgum,
tibial torsion, femoral anteversion, limb-length discrepancy)
can influence both the natural history and the severity of
pediatric flatfoot.
Flatfoot can be associated with a number of subjective
symptoms that may include pain in the foot, leg, and knee, and
postural symptoms. A history of trauma—acute or repetitive—
may cause or unmask the foot deformity. Flatfoot deformity
may result in decreased endurance and voluntary withdrawal
341
 PATHWAY 1
from physical activities. Previous treatment may have modified
the clinical presentation (4). A comprehensive history and
review of systems may show previously unsuspected medical
conditions (4). For example, a history may disclose clumsiness
and frequent falling. Difficulty climbing and difficulty arising
from the floor in association with flatfoot may indicate Becker
or Duchenne muscular dystrophy.
Significant Findings (Pathway 1, Node 2)
The appearance of the foot during weightbearing and
nonweightbearing suggests the presence and type of flatfoot
deformity (Fig 1). Physical findings may include low arch
structure, rearfoot eversion, medial talar head prominence,
altered walking, and the presence of calluses.
Evaluation of flatfoot requires assessment of ankle dor-
siflexion and plantarflexion (with knee extended and flexed)
and rearfoot, midfoot, and forefoot ranges of motion. The
342 THE JOURNAL OF FOOT & ANKLE SURGERY
forefoot-to-rearfoot relationship is also assessed. Tender-
ness may be present in pediatric flatfoot, occurring along the
medial column and at the metatarsal heads, plantar fascia,
sinus tarsi, and ankle.
Gait observation should be conducted when the child is
barefoot and is wearing shoes. Gait should be assessed
for prominence of the medial border of the midfoot, the
foot progression angle, calcaneal eversion (pronation and
resupination during stance phase), the heel-to-toe con-
tact, position of the knee, and presence of limp.
Diagnostic observations and maneuvers include inver-
sion of the heel on toe rise, recreation of the medial arch
with dorsiflexion of the hallux, and the “too many toes
sign.” Other physical findings include obesity, tibia va-
rum, genu valgum, tibial torsion, femoral torsion, disor-
ders of muscle tone, and ligamentous laxity that can
modify both the natural history and the severity of flat-
foot (9).
FIGURE 1 Clinical examination of the foot begins with nonweightbearing inspection. (A) The pediatric flexible flatfoot shows preservation
of the medial arch off weightbearing, whereas (B) the arch depresses or flattens with weightbearing. (C) The relaxed calcaneal stance position
is viewed from the posterior. The heels may evert and the tendo-Achilles bows laterally (positive Helbing sign). (D) Ankle dorsiflexion is
assessed during the examination, because equinus is a frequent component or etiologic factor of flatfoot pathologies. (E) The everted or
valgus heel in stance changes to (F) a varus position with the clinical maneuver of heel rise to the toes, showing the flexible nature and the
reducibility of the deformity.

VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 343

Diagnostic Studies (Pathway 1, Node 3)

Imaging options may include radiographs (Fig 2)

(weightbearing), computed tomography (CT), magnetic res-
onance imaging (MRI), and bone scans. Serologic studies
may be warranted to differentiate mechanical or overuse
symptoms from arthralgia, arthritis, and other childhood
inflammatory diseases.

Diagnosis (Pathway 1, Node 4)

Information from the initial evaluation and diagnostic

tests is correlated into a diagnosis. The differential diagnosis
of the pediatric flatfoot includes the following: flexible
flatfoot (Pathway 2); rigid flatfoot: congenital vertical talus
(CVT) (Pathway 3); tarsal coalition (Pathway 4); peroneal
spastic flatfoot without coalition (Pathway 5); iatrogenic
and posttraumatic deformity (Pathway 6); skewfoot (Path-
way 7); and flatfoot caused by other, less frequent causes
(Pathway 8) (2, 4, 8, 10). Note that 4 of these conditions—
vertical talus, tarsal coalition, peroneal spastic flatfoot with-
out coalition, and iatrogenic/posttraumatic deformity—are
types of rigid flatfoot.

Flexible Flatfoot (Pathway 2)

Asymptomatic Flexible Flatfoot (Pathway 2)

The asymptomatic flexible flatfoot may be physiologic or

nonphysiologic (Nodes 5 and 6) (11). Most flexible flatfeet
are physiologic, asymptomatic, and require no treatment (7,
12, 13). Physiologic flexible flatfoot follows a natural his-
tory of improvement over time (Fig 3). Periodic observation
may be indicated to monitor for signs of progression (Node
5). Treatment generally is not indicated (14).
Nonphysiologic flexible flatfoot is characterized by pro-
gression over time. The degree of deformity is more severe
in nonphysiologic than in physiologic flexible flatfoot. The
amount of heel eversion is excessive; the talonavicular joint
is unstable. Additional findings include tight heel cords and
gait disturbance. Periodic observation is indicated in non-
physiologic flexible flatfoot (Node 7). Patients with tight
heel cords may benefit from stretching (Node 8) (13). Or-
thoses may also be indicated.
Children with asymptomatic flexible flatfoot should be
monitored clinically for onset of symptoms and signs of
progression (Node 7). Continued progression requires reas-
sessment to identify other underlying disease.
Symptomatic Flexible Flatfoot (Pathway 2, Node 6)
Unlike physiologic and asymptomatic nonphysiologic
flexible flatfoot, symptomatic forms of flexible flatfoot
FIGURE 2 Radiographic examination includes weightbearing (A)
AP and (B) lateral radiographs taken in the angle and base of gait
for further evaluation and documentation of the degree of
deformity. Radiographic flatfoot parameters focus on the rela-
tionship of the talus and calcaneus. The midtalar line (solid black
line), talocalcaneal angle (TC) and calcaneal inclination angle
provide information on the sagittal plane position of these bones
on lateral view and transverse plane position on the AP view. In
flatfoot, the talocalcaneal angle increases in size both on the AP
and lateral radiographs. The talus plantarflexes in flatfoot
deformity on the lateral radiograph. The normal midtalar line
should pass through the first metatarsal. On the weightbearing
AP radiograph, the talar head is no longer covered by its articu-
lation with the navicular. This results in a wide AP talocalcaneal
angle (Kite angle). Calcaneal inclination decreases in flatfoot.
(Further discussion can be found in the American College of Foot
and Ankle Surgeons Clinical Practice Guideline on Adult Flatfoot.)
produce subjective complaints, alter function, and produce
significant objective findings. These include pain along the
medial side of the foot; pain in the sinus tarsi, leg, and knee;
decreased endurance; gait disturbances; prominent medial talar
head; everted heels; and heel cord tightness.
Initial treatment (Node 8) includes activity modifica-

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VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 345

tions and orthoses. Stretching exercises for equinus
deformity can be performed under physician or physical
therapist supervision. Nonsteroidal antiinflammatory
medications may be indicated in more severe cases. Co-
morbidities, such as obesity, ligamentous laxity, hypoto-
nia, and proximal limb problems, must be identified and
managed, if possible.
346 THE JOURNAL OF FOOT & ANKLE SURGERY
If there is a positive clinical response and symptoms
are resolved, observation and orthoses (when appropri-
ate) are instituted. If clinical response is not satisfactory,
reassessment and additional work-ups are indicated.
When all nonsurgical treatment options have been ex-
hausted, surgical intervention can be considered (13,
15–21).
Surgical Intervention (Pathway 2, Node 10)
Surgical management of the flexible flatfoot can be
grouped into 3 types: reconstructive procedures, arthrodesis,
and arthroereisis.
Soft tissue reconstruction of the flexible flatfoot is rarely
successful as an isolated procedure. Bony procedures in-
clude rearfoot, midfoot, and forefoot osteotomies. Depend-
ing on the plane of dominance of the deformity, lateral
column lengthening (Fig 4) and/or medial displacement
osteotomy of the posterior calcaneus may be used. A heel
cord lengthening and medial plication are often included as
a part of these procedures. Although excellent results from
surgical treatment of flatfoot have been described, questions
remain regarding successful long-term correction (14).
Arthroereisis involves insertion of a spacer into the sinus
tarsi for the purpose of restricting subtalar joint pronation
(22–25) (Fig 5). Proponents of this procedure argue that it is
a minimally invasive technique that does not distort the
normal anatomy of the foot (24, 26 –28). Others have ex-
pressed concern about placing a permanent foreign body
into a mobile segment of a child’s foot (29, 30). The
indication for this procedure remains controversial in the
surgical community (25, 26, 28, 31–38).
Arthrodesis of the rearfoot has also been described for
treatment of symptomatic flexible flatfoot. Subtalar arthro-
desis is typically performed as the primary procedure. Triple
arthrodesis is reserved as a salvage procedure for previously
failed surgical treatment. Although arthrodesis provides a
FIGURE 3 Radiographic examination of foot deformities is essen-
tial for both diagnostic evaluation and documentation. Radiographs
of pediatric deformities allow comparison of progression with time
and assessment of therapeutic results. This case is a neurologically
healthy 4-year-old girl who was treated for flexible flatfoot with
nonpronating orthotics. (A) The initial AP and lateral radiographs
show medial talar head uncovering and a wide talocalcaneal angle.
(B) The initial lateral radiograph shows decreased calcaneal inclina-
tion angle and increased talar declination angle. (C) Three years
later, there is improvement in the radiographic parameters with
increased talar head coverage on the AP view. (D) The lateral
radiograph shows improvement of arch height, although the calca-
neal inclination and talar declination are similar to the pretreatment
studies. Although it is tempting to credit orthotic therapy for the
observed improvement, it is equally possible that these changes are
the result of the natural history of spontaneous improvement.
 FIGURE 4

VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 347

stable foot and durable correction, eventual transfer of en-
ergy to the nonfused joints adjacent to the fusion is of
concern (39, 40).
If surgical intervention is successful in producing a func-
tional painless result, the child should be further treated by
periodic observation and appropriate orthoses. If surgery
fails, salvage through appropriate intraarticular or extraar-
ticular arthrodesis is appropriate.
Significant History (Pathway 3, Node 1)
CVT deformity should be diagnosed at birth but it is
sometimes confused with calcaneovalgus deformity or
physiologic flatfoot. Symptoms begin at walking age, with
difficulty bearing weight and wearing shoes. There may be
a history of previous unsuccessful treatment.

Significant Findings (Pathway 3, Node 2)

Rigid Flatfoot (Pathway 3 to 6)
Rigid flatfoot is characterized by a lowered arch on both
weightbearing and nonweightbearing and by a decrease or
absence of motion of the rearfoot and midfoot. Rigid flatfoot
can be symptomatic or asymptomatic. Most cases are asso-
ciated with underlying primary pathology that can be diag-
nosed by clinical and imaging examinations.
The differential diagnosis of rigid pediatric flatfoot in-
cludes CVT (Pathway 3), tarsal coalition (Pathway 4), per-
oneal spastic flatfoot without coalition (Pathway 5), and
iatrogenic or traumatic joint pathology (Pathway 6).
Congenital Vertical Talus (Pathway 3)
CVT deformity, also known as congenital convex pes
valgus, is characterized by severe equinus of the rearfoot
and by a rigid rocker-bottom appearance. There are 2
classes of this deformity: teratologic and idiopathic.
Teratologic CVT indicates the presence of underlying
comorbid conditions. These include genetic syndromes, spi-
nal dysraphisms (41– 43), prune belly syndrome (44), de
Barsy syndrome (45), distal arthrogryposis (46), arthrogry-
posis multiplex congenita (47), congenital metacarpotalar
syndrome (48), Rasmussen syndrome (49 –51), and a host of
chromosomal abnormalities (52).
Idiopathic CVT lacks specific etiologic factors (52– 61).
CVT has been associated with a tarsal coalition (62). Ge-
netic issues in idiopathic CVT have not been resolved
because of inconclusive data. Results of some studies sug-
gest a hereditary component (58, 63, 64), whereas others fail
to show patterns of inheritance (65, 66).
CVT is characterized by a rigid rocker-bottom appear-
ance to the foot (Fig 6). Pathology findings include dorsal
dislocation of the talonavicular joint, ankle equinus, con-
tracture of the tendo-Achilles, long-toe flexors, posterior
ankle capsule, peroneal tendons, and the anterior compart-
ment tendons (59, 67). The tibionavicular ligament is con-
tracted; the calcaneonavicular (spring) ligament is elon-
gated.
The forefoot is most frequently abducted, but may occa-
sionally be adducted (68). The calcaneocuboid articulation
often remodels so that the entire plantar aspect of the foot is
convex (68). Tibialis posterior and the peroneals may be
displaced, the talar head becomes misshapen, and the de-
formity is extremely rigid. It is most likely resistant to
closed reduction (53, 66, 69 –71).
Diagnostic Imaging (Pathway 3, Node 3)
Plain radiographs are most often diagnostic (61). Lat-
eral weightbearing radiographs show parallelism between
the tibia and the talus. The calcaneus is in equinus
(Fig 6).
If the navicular has not ossified, a plantarflexion stress
lateral radiograph will determine the reducibility of the
forefoot on the talus. The longitudinal axis of the first
metatarsal will not align with the bisection of the talus. If
the navicular has already ossified, its malposition in refer-
ence to the talus is visualized. It is not reduced on plantar-
flexion.
On the anteroposterior (AP) projection, the talocalcaneal
(Kite) angle will be very wide. The navicular (if visualized)

FIGURE 4 Selection of apropriate surgical treatment is based on the clinical and radiographic evaluation. Planal dominance is an important
factor. A flatfoot deformity will usually show significant deformity in one or more of the cardinal body planes. A 12-year-old boy had a 2-year
history of progressing pain in both feet after walking long distances and after athletic activities. (A) The medial border of the foot is
characterized by talar-head bulging and by the loss of medial arch height. (B) The lateral border is abducted and the calcaneus is everted.
(C) The midtarsal joint complex is pronated on the AP radiograph, and the talar head is uncovered. (D) The lateral radiograph shows abnormal
calcaneal inclination, increased talocalcaneal angle, and sagittal collapse of the medial column. The patient underwent an Evans opening
calcaneal osteotomy with insertion of banked bone graft, a plantarflexing first metatarsal osteotomy, and a percutaneous tendo-Achilles
lengthening. (E and F) Marked improvement in the talocalcaneal angle, and improved calcaneal inclination and height of the medial arch, are
seen on the AP and lateral postoperative radiographs.

348 THE JOURNAL OF FOOT & ANKLE SURGERY

FIGURE 5 Arthroereisis is an evolving procedure for the
treatment of flexible flatfoot. Both polymer and metallic
implants are commercially available. (A) This weightbearing
preoperative AP radiograph shows a wide talocalcaneal
angle with approximately 50% of the medial talar head
uncovered. The midtarsal joint complex is completely
pronated. (B) The preoperative lateral radiograph shows a
large lateral talocalcaneal angle, decreased calcaneal incli-
nation angle, anterior alteration of the Cyma line, and mid-
tarsal fault. (C) After metallic subtalar arthroereisis, the
postoperative AP shows the talonavicular joint completely
reduced. The AP talocalcaneal (Kite) angle is also reduced
compared with the preoperative study. (D) The postopera-
tive lateral shows significant change in the talotibial and
talocalcaneal relationships. The forefoot is supinated.
(Case courtesy of John Grady, DPM, Chicago, IL.)

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350 THE JOURNAL OF FOOT & ANKLE SURGERY


FIGURE 6 Rigid flatfoot deformities are often congenital. Vertical
talus is 1 pathology that should be diagnosed early in life. (A) A child
with CVT (congenital convex pes valgus) is characterized clinically
by a pathologic plantigrade foot with weight borne at the midfoot
and the heel off the ground. (B) The lateral radiograph shows the
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004
will be displaced laterally and will appear to overlap the
distal aspect of the talar head.
MRI, CT, and ultrasound studies may be useful in imag-
ing the deformity for diagnosis and for surgical planning
(72–75).
Diagnosis (Pathway 3, Node 4)
Diagnosis of vertical talus is made by the appearance of
a rigid and irreducible foot, with support from imaging
studies. The differential diagnosis must include calcaneo-
valgus deformity, which is flexible, does not have a rocker-
bottom configuration, and does not have a talonavicular
dislocation (76).
Initial Treatment (Pathway 3, Node 5)
Initial management of CVT consists of manipulation and
serial casting for approximately 6 weeks (77). During ma-
nipulation, an attempt is made to pull the navicular distally,
downward, and medially to relocate it on the talar head.
If closed reduction occurs (Node 6), the talonavicular
joint can be pinned in percutaneous fashion (Fig 7). At that
point, the equinus may be corrected by casting. If complete
reduction is achieved, an ankle-foot orthosis can be pre-
scribed (Node 7). The patient must be carefully observed
because of an extremely high recurrence rate.
Surgical Intervention (Pathway 3, Node 8)
Long-term results of closed reduction have been reported
as poor (70). If closed reduction is not successful, open
surgical reduction is necessary (65, 66, 68, 69, 77, 78).
Reduction may be performed in 1 (52, 53, 59, 79, 80) or 2
(68, 81) stages. The benefits and value of the 2 techniques
have been examined by a number of authors (54, 82).
For infants, the Cincinnati incision gives excellent expo-
sure to the rearfoot components of the deformity (61).
However, this incision is not recommended for older chil-
dren because of concerns about skin perfusion after this
approach (83). The goal of surgery is to correct hindfoot
equinus, to restore talonavicular congruity, and to restore
functional anatomy. Recurrence is a common problem and
bracing is recommended (Fig 7).
In older children, the talonavicular joint may be so de-
ankle and calcaneus in equinus position, the talus almost vertical,
and the talonavicular joint dislocated. The navicular is not ossified,
but a line passing through the first metatarsal shaft intersects the
dorsal talar neck instead of the talar head. (C) A stress plantarflexion
radiograph is diagnostic and shows that only partial reduction of the
talonavicular dislocation is possible.
351
FIGURE 7 Vertical talus is generally irreducible nonsurgically. This 3-year-old neurologically healthy girl was diagnosed at 22 months with
CVT deformity. Nonsurgical reduction was not successful. (A) The initial surgical approach is peritalar release and pinning of the talonavicular
joint. (B and C) These radiographs show some recurrence of the deformity after peritalar release. Note the deformed navicular and severe talar
declination combined with a rocker-bottom deformity.

352 THE JOURNAL OF FOOT & ANKLE SURGERY


FIGURE 8 Recurrence of vertical talus deformity is not uncommon
and may require further treatment with bracing or additional surgery.
(A) This radiograph shows recurrent deformity in a young girl with
myelomeningocele. Equinus of the talocalcaneal complex, rocker-
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004
formed that reconstruction is not possible. For these pa-
tients, naviculectomy may be the procedure of choice (53,
84 – 86). The Green-Grice procedure for extraarticular sta-
bilization may also be used (53, 58, 87– 89) (Fig 8). It may
be necessary to consider lateral column lengthening (87),
osteotomy of the calcaneus, and subtalar arthrodesis to
maintain the corrected position. Talectomy may also be
indicated in selected cases (68). Tendon transfer for rebal-
ancing is frequently added in the surgical treatment plan.
Continued observation and appropriate orthosis therapy fol-
lows.
Tarsal Coalition (Pathway 4)
Tarsal coalition is a congenital union between 2 or more
tarsal bones that may be an osseous, cartilaginous, or a
fibrous connection (90, 91). The incidence of tarsal coalition
is 1% to 2% (90 –92). Talocalcaneal and calcaneonavicular
bars are the most common. Talocalcaneal coalitions are
most commonly found at the middle facet (90, 91, 93, 94).
Talonavicular and calcaneocuboid coalitions also have been
described but are much less common. Autosomal dominant
inheritance has been proposed (90, 95–97).
Significant History (Pathway 4, Node 1)
Tarsal coalitions may be asymptomatic (91). The child
and parents may become aware of stiffness in the foot and
ankle, altered foot shape, muscle spasm, and protective gait
abnormalities. Symptoms of tarsal coalitions most com-
monly present in preadolescents or adolescents who sud-
denly gain weight and who take on physical activities, such
as sports and forms of manual labor. Onset of symptoms
may be insidious, precipitated by minor trauma or change in
activity (98, 99).
Significant Findings (Pathway 4, Node 2)
Most symptomatic coalitions present with local tender-
ness around the lateral ankle, sinus tarsi, subtalar joint, or
the coalition site. There is decreased or absent rearfoot
range of motion with or without muscle spasm and some
degree of rigid flatfoot.
bottom deformity, and talonavicular subluxation are present. (B) The
patient was treated with a Green-Grice extraarticular subtalar arth-
rodesis. (C) Excellent reduction of deformity is seen immediately
postoperative and is maintained on the follow-up radiograph. (Case
courtesy of Loyola University Department of Orthopaedics and Re-
habilitation Pathology Collection, Maywood, IL.)
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354 THE JOURNAL OF FOOT & ANKLE SURGERY

FIGURE 9 Tarsal coalitions account for most rigid flatfoot deformities seen at the community level. (A) Talonavicular coalition may be seen
as an incidental finding. These feet are usually asymptomatic. Calcaneonavicular bars are common. (B) The lateral radiograph shows an
exaggerated projection of the distal calcaneus (anteater sign). (C) Lateral oblique projection shows the connection between the calcaneus and
the navicular. (D and E) MRI and CT imaging techniques better delineate the pathology. The talocalcaneal coalition may be diagnostically
more difficult. (F) The lateral radiograph may show irregularity of the middle facet or complete obliteration of the middle facet. (G) Special
views, such as the Harris-Beath projection, should show parallel relationship between the middle and posterior facets. (G) Shown here is an
oblique and poorly visualized middle facet. (H) This is verified with a CT image.

VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 355

Diagnostic Imaging (Pathway 4, Node 3) TABLE 1 Classification of tarsal coalitions

Tissue types Anatomic

Calcaneonavicular coalitions can be seen on both lateral Extraarticular
and oblique radiographs of the foot as an upward and medial Cartilaginous Calcaneonavicular
prolongation of the calcaneus toward the inferolateral na- Fibrous Cuboidonavicular
vicular (Fig 9). Depending on the degree of ossification of Osseous Trigonal
Intraarticular
the bridge, there may be a lucent line separating the 2 bones.
Talocalcaneal
The 45° oblique plain radiographic view is best for detec- Middle
tion of the calcaneonavicular coalition. Posterior
Middle facet talocalcaneal coalitions are difficult to visu- Anterior
alize because of the complexity of the anatomy and because Combination
Talonavicular
many are cartilaginous. The lateral radiograph may show
Calcaneocuboid
the “C” or halo sign (the C-shaped line formed by the Naviculocuneiform
medial outline of the talar dome and sustentaculam tali,
Articular
which is a secondary sign of a coalition) (100). Harris-Beath
projections may be useful, but they may be difficult to Juvenile (osseous immaturity) Adult (osseous maturity)
interpret because of problems with underpenetration. If pos- Type I: Extraarticular coalition Type I: Extraarticular coalition
A. No secondary arthritis A. No secondary arthritis
itive, the articular end plates of the middle facet are irreg-
B. Secondary arthritis B. Secondary arthritis
ular, the facets angulate down and medial, and there may be Type II: Intraarticular coalition Type II: Intraarticular coalition
partial bridging evident (101). If angulation is more than A. No secondary arthritis A. No secondary arthritis
20°, coalition is probable (90, 93, 102). Because of the B. Secondary arthritis B. Secondary arthritis
difficulty of interpretation, CT and MRI studies have largely
replaced Harris-Beath projections (Fig 9).
CT is the diagnostic test of choice because of its ability to
show the osseous structures (103–105). It is particularly weeks may be indicated for patients with more severe
useful for visualizing talocalcaneal coalitions and for eval- symptoms or with peroneal spasm (97).
uating multiple coalitions. Coronal images show the loca-
tion and extent of their involvement (106 –111, 112).
Clinical Response (Pathway 4, Node 6)
MRI is particularly useful in evaluating the immature
skeleton and in determining the presence of other causes of
After a period of nonsurgical treatment, patients should
peritalar pain (90, 103). It is helpful in evaluating fibrocar-
be reevaluated. If symptoms have been relieved, the initial
tilagenous coalitions and nonossified coalitions in the very
treatment options should be continued (Node 7), with peri-
young (90, 113–116).
odic observation of clinical progress (Node 8).
Bone scans have been used to show increased stresses at
articular surfaces. Bone scans are sensitive but nonspecific
(117–119). Surgical Intervention (Pathway 4, Node 9)

Surgical consideration should be given to those who fail

Diagnosis (Pathway 4, Node 4)
Diagnosis of tarsal coalition is based on pain and loss of
motion and supported by appropriate imaging studies. Co-
alitions are classified by site, type of interposing tissue,
extent of involvement, and secondary degenerative changes
(Table 1).
Initial Treatment (Pathway 4, Node 5)
The initial treatment for any coalition should be nonsur-
gical (90, 120 –122). Patients with mild symptoms may
respond well to footwear modifications, arch supports, or
custom orthoses. Activity modifications, weight reduction,
antiinflammatory medication, and local anesthetic blocks
may also be indicated (90). Cast immobilization for several
to respond to nonsurgical treatment (6, 101, 122). Surgical
treatment depends on the type of coalition. Resection of the
coalition may be indicated for individuals without signifi-
cant deformity or arthrosis (Fig 10). In some cases, arthro-
desis may be the procedure of choice.
In children with foot deformity, osteotomy should be
performed in conjunction with resection. If significant ar-
thritic changes are found, arthrodesis should be considered.
Isolated talocalcaneal arthrodesis is indicated for subtalar
coalitions (96). If peritalar degeneration is evident, triple
arthrodesis may also be indicated (Fig 11) (101, 102,
120, 122).
Observation and supportive orthoses should follow sur-
gery (Node 8). If symptoms recur, the patient may need to
return to nonsurgical options. These measures are not likely
to provide adequate relief of symptoms.

356 THE JOURNAL OF FOOT & ANKLE SURGERY

FIGURE 10 Calcaneonavicular coalitions may be fibrous, cartilaginous, or osseous. Younger patients may benefit by excision of the bar.
(A and B) Oblique and lateral radiographs demonstrate the bar as well as the pronatory foot deformity. (C) Shown is an intraoperative view
of the excised fragment. Excision should restore the mobility of the rearfoot complex. (D and E) The postoperative oblique and lateral
radiographs show adequate resection of the extraarticular bar.

VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 357

FIGURE 11 Talocalcaneal coalitions limit or prevent normal joint motion. Once they occur, degenerative joint changes are irreversible.
Treatment in the older adolescent or young adult usually requires subtalar or triple arthrodesis. (A and B) AP and lateral radiographs show
significant pronatory foot deformity with low calcaneal inclination, increased talar declination, and depression of the medial column. Clinically,
no subtalar motion is present. (C) MRI evaluation shows a middle subtalar facet coalition. (D and E) Surgical treatment with triple arthrodesis
restored rearfoot relationships and eliminated pain.

358 THE JOURNAL OF FOOT & ANKLE SURGERY

Peroneal Spastic Flatfoot Without Coalition
(Pathway 5)
Peroneal spastic flatfoot without coalition is a painful foot
deformity made rigid by spasm of the extrinsic muscles.
Although tarsal coalition is the most common cause of
peroneal spastic flatfoot (see Pathway 4) (123–132), its
presence cannot be confirmed in a number of cases. Other
possible causes (133) include juvenile chronic arthritis
(134), osteochondral fractures in the rearfoot, osteoid os-
teoma, neoplasms (135), dysplasia epiphysealis hemimelica
(Trevor disease) (136), and problems more proximal in the
limb (slipped capital femoral epiphysis) (137). When no
cause can be found, the condition has been labeled idio-
pathic peroneal spastic flatfoot.
Significant History (Pathway 5, Node 1)
The patient develops pain in the foot, followed by pro-
tective limitation of motion by the extrinsic muscles. Pain is
experienced with activity, and symptoms may be precipi-
tated by trauma. Many patients have been previously eval-
uated for tarsal coalition, but there have been no objective or
imaging findings to support the diagnosis.
Significant Findings (Pathway 5, Node 2)
Peroneal muscle spasm, restricted subtalar and ankle mo-
tion, valgus appearance of the foot, and constant or inter-
mittent pain in response to activity are the hallmarks of the
condition. Clinical findings are not limited to the peroneal
muscles alone. The extensors, tibialis anterior, and tibialis
posterior are involved.
Gait pattern is antalgic with external rotation of the foot
to the line of progression. There is little or no propulsion
during late stance phase of gait.
Diagnostic Studies (Pathway 5, Node 3)
Diagnostic imaging that fails to show a tarsal coalition or
typical secondary findings of a tarsal coalition (see Pathway
4) may show other pathologies that might explain the con-
dition such as osteochondral defect, pathologic fracture
through a bone cyst, or osteomyelitis (Fig 12).
A preliminary bone scan may help localize the pathology.
A total body bone scan is useful to rule out otherwise silent
multiple anatomical sites in systemic disease. In some cases,
all imaging studies may be normal and further clinical
investigation is indicated.
Laboratory studies (Node 4) should include a complete
blood cell count with differential and acute phase reactants
(erythrocyte sedimentation rate and C-reactive protein). El-
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004
evated inflammatory markers suggest a rheumatologic cause
and merit further investigation or consultation (Node 5).
Diagnosis (Pathway 5, Node 6)
Peroneal spastic flatfoot without coalition is a diagnosis
of exclusion and may be ultimately considered idiopathic.
Initial Treatment (Pathway 5, Node 7)
When a specific cause is detected, appropriate treatment
is directed toward that cause. If no cause can be identified,
symptoms dictate the type of treatment. When symptoms
are intermittent, activity modifications may prove useful.
This may include stopping sports, discouraging running and
jumping activities, and taking the child out of physical
education class. Activity modifications can be supple-
mented with nonsteroidal antiinflammatory medications.
Footwear modifications, arch supports, and orthosis may
also be beneficial.
In more difficult cases, immobilization in a walking boot
may prove helpful. However, patient compliance is often a
problem. This can be solved with a nonweightbearing be-
low-knee cast and crutches. In extreme cases, an above-
knee cast can be considered. Common peroneal nerve
blocks can be both therapeutic and diagnostic.
Clinical Response (Pathway 5, Node 8)
If clinical response to treatment results in resolution of
the symptoms and restoration of painless range of mo-
tion, follow-up orthotic treatment may be indicated and
the patient should be observed periodically (Nodes 9 and
10).
Surgical Intervention (Pathway 5, Node 11)
If symptoms do not resolve with nonsurgical treatment,
surgical options can be considered (Node 11). Surgical
procedures include arthrodesis and realignment osteotomy.
Observation and supportive orthoses should follow surgery
(Node 10).
Iatrogenic and Posttraumatic Deformity (Pathway 6)
Iatrogenic and posttraumatic flatfoot are uncommon
and encompass a broad spectrum of foot disorders. Man-
agement can be challenging and complex, necessitating
case-by-case consideration. Surgical treatment of infant
foot deformities often results in undercorrection or over-
359
 PATHWAY 5

360 THE JOURNAL OF FOOT & ANKLE SURGERY


correction. This is particularly true for talipes equinova-
rus (138 –144). The goal of treatment is a flexible, plan-
tigrade, painless foot. In many cases, a perfect outcome is
not possible. Often, the end result is a rigid and, hope-
fully, plantigrade foot.
VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004
FIGURE 12 Rigid flatfoot deformity with peroneal spasm may
occur in the absence of coalition. Multiple etiologies have been
implicated. (A) This is an adolescent patient with a medial talar
dome lesion that produced the patient’s symptoms and (B)
flatfoot deformity. Other pathologies include lesions of rearfoot
bones. (C and D) Plain films and CT images of an osteoid
osteoma of the talar neck that produced a symptomatic rigid
flatfoot.
Etiologic factors include overcorrected clubfoot (Fig 13),
undercorrected vertical talus (145–148), failed flatfoot sur-
gery, and end-stage trauma. Iatrogenic or posttraumatic
flatfoot may also be caused by manipulation or casting of
the pliable, easily damaged infant foot.
361
 PATHWAY 6

362 THE JOURNAL OF FOOT & ANKLE SURGERY

 FIGURE 13 (A and B) The long-term results of posteromedial release of clubfoot deformity.
There has been overcorrection, resulting in rigid flatfoot deformity and marked sagittal breech
with subluxation of the talonavicular articulation. The first ray is supinated with metatarsus primus
elevatus.

Significant History (Pathway 6, Node 1) Initial Treatment (Pathway 6, Node 5)

Patients with iatrogenic or posttraumatic flatfoot present
with variable degrees of pain, loss of function, and progres-
sive deformity. All feet in this category have a history of
previous manipulation, surgery, or trauma. Onset of flatfoot
deformity may be either immediate or delayed by months or
years.
Significant Findings (Pathway 6, Node 2)
Examination may determine pain, stiffness, scarring, ab-
normal function, and gait disturbances.
Shoe modifications and bracing may be indicated in the
initial management of these deformities. Activity modifica-
tions, weight reduction, physical therapy, and nonsteroidal
antiinflammatory medication may be helpful.
Clinical Response (Pathway 6, Node 6)
If the clinical response is satisfactory, continued nonsurgical
management and observation are in order (Nodes 7 and 8).

Surgical Intervention (Pathway 6, Node 9)

Diagnostic Imaging (Pathway 6, Node 3)
Plain radiographs may show postsurgical changes, re-
tained implants and hardware, malalignment, and arthri-
tis. CT, MRI, and bone scans may be useful in further
defining the deformity and in evaluating residual pathol-
ogy.
Diagnosis (Pathway 6, Node 4)
The patient’s history, coupled with diagnostic imaging, con-
firms the diagnosis of iatrogenic or posttraumatic flatfoot.
If there is no response to nonsurgical treatment, surgical
intervention (Node 9) may be necessary to achieve the goal of
a stable pain-free plantigrade foot. The specific procedures are
directed to the deformity, the condition of the soft tissues, and
the joints and osseous structures. Patient and parental educa-
tion should be provided to encourage realistic expectations.
Soft tissue release, osteotomy, and arthrodesis (145–148)
are the procedures most frequently used. In certain cases,
severe deformities may be realigned with distraction osteo-
genesis (Ilizarov) (139). Rarely, in the case of intractable
pain and unstable deformity or chronic osteomyelitis, an

VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 363

amputation followed by a functional prosthesis is a reason-
able choice to allow the patient to return to activities.
Patients should be followed up for observation (Node 8).
Recurrence is possible and necessitates reevaluation.
Skewfoot (Pathway 7)
Skewfoot is characterized by forefoot adduction (meta-
tarsus adductus) and heel valgus (149 –151). The more
severe cases have midfoot abduction. There are no univer-
sally accepted clinical or radiographic criteria for skewfoot
(150) and the natural history of idiopathic skewfoot is
poorly understood (150, 152, 153). There are 4 types of
skewfoot: congenital idiopathic, congenital associated with
syndromes, neurogenic, and iatrogenic (151).
Significant History (Pathway 7, Node 1)
Skewfoot may be asymptomatic or associated with
activity-related pain and difficulty in fitting shoes (150,
154). It is often misdiagnosed as metatarsus adductus and
flexible flatfoot. Skewfoot should be suspected if the
infant does not respond favorably to treatment for meta-
tarsus adductus.
Significant Findings (Pathway 7, Node 2)
The deformity is characterized as an S- or Z-shaped foot
with forefoot adductovarus and rearfoot valgus (149) (Fig 14).
In children younger than 1 year of age, the rearfoot valgus is
not as apparent as the forefoot deformity (151). Contracture of
the tendo-Achilles may be present (150, 151). Calluses and
other skin problems may occur (150, 154).
Diagnostic Imaging (Pathway 7, Node 3)
Standard radiographs show metatarsus adductus and se-
vere heel valgus (Fig 14).
364 THE JOURNAL OF FOOT & ANKLE SURGERY
Diagnosis (Pathway 7, Node 4)
Clinical findings and supportive radiographs confirm the
diagnosis of skewfoot.
Initial Treatment (Pathway 7, Node 6)
Asymptomatic skewfoot in older children needs no treat-
ment (Node 5). Management of skewfoot is based on age,
degree of severity, and presence of symptoms (155). Ma-
nipulation and serial casting may be indicated for infants
(155). Stretching exercises and activity modification may
relieve mild symptoms but they will not change the defor-
mity (150). Orthoses may be used for symptomatic relief but
may exacerbate the symptoms in the presence of ankle
equinus (150). Nonsteroidal antiinflammatory medications
may also be beneficial. Management of comorbid condi-
tions is important.
Clinical Response (Pathway 7, Node 7)
Clinical response to treatment is evaluated. Observation
and continuation of initial treatment options are recom-
mended for children whose symptoms resolve (Node 8).
Surgical Intervention (Pathway 7, Node 9)
Persistence of severe symptoms may require surgical
intervention. Surgical treatment must address both the fore-
foot and the rearfoot components (Fig 15). Useful proce-
dures include metatarsal osteotomies and midfoot osteot-
omy to correct the forefoot. Lateral column lengthening,
calcaneal displacement osteotomy, and tendo-Achilles
lengthening are used to correct the rearfoot (149 –151,
155, 156).
 PATHWAY 7

VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 365

FIGURE 14 Skewfoot, an uncommon but very severe variant of the flatfoot deformity, is characterized by rearfoot pronation, midfoot abduction,
and metatarsus adductus. (A) This clinical photograph of an adolescent patient with skewfoot shows forefoot adduction— unlike forefoot abduction
seen with most other flatfoot deformities. (B) The AP radiograph shows very prominent metatarsus adductus deformity with a large talocalcaneal
angle. (C) The lateral radiograph shows sagittal plane failure of the medial column with talar ptosis (pathologic declination).

366 THE JOURNAL OF FOOT & ANKLE SURGERY

FIGURE 15 Surgical treatment of skewfoot requires addressing the forefoot and rearfoot
pathologies separately. (A) The AP radiograph is generally diagnostic. There is a Z orientation of
the rearfoot, midfoot, and forefoot areas. (B) The lateral radiograph shows the typical findings of
pronatory deformity. (C and D) AP and lateral radiographs show the surgical results of meta-
tarsal–first cuneiform arthrodesis in combination with lesser metatarsal osteotomies to correct
the metatarsus adductus, and a lateral column lengthening osteotomy of the calcaneus (Evans
procedure).

VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 367

Other Causes of Pediatric Flatfoot (Pathway 8)
Some forms of pediatric flatfoot deformity do not fit
into the previous schemes. They are unique because their
clinical findings are dictated by the underlying pathology.
Additionally, the clinical approach to diagnosis and treat-
ment is dependent on the cause. Some have natural
histories that are totally unpredictable, and early inter-
vention is undesirable until the problem has fully ex-
pressed itself.
Significant History (Pathway 8, Node 1)
These forms of pediatric flatfoot are associated with
generalized ligamentous laxity; Marfan disease; Ehlers-
Danlos; and Down syndrome, cerebral palsy, myelomenin-
gocele, developmental delay, genetic diseases, and other
syndromes (Fig 16).
Significant Findings (Pathway 8, Node 2)
A variable pattern of foot deformities may be seen. The
deformities range from hypermobile to rigid. Physical ex-
amination of these children must include observational gait
analysis, assessment of generalized joint mobility for hy-
perlaxity and hypolaxity, and thorough neurologic exami-
nation. Examination of the foot for mobility, calluses, and
skin irritation is necessary.
Diagnostic Imaging (Pathway 8, Node 3)
Diagnostic imaging should be performed as clinically
indicated.
368 THE JOURNAL OF FOOT & ANKLE SURGERY
Diagnosis (Pathway 8, Node 4)
There is nothing unique about this group of pathologies
that has not been previously discussed. Refer to previous
pathways for detailed discussion.
Initial Treatment (Pathway 8, Node 6)
In planning the treatment of flatfoot in children with
underlying diseases, it is important to consider the patient’s
baseline function, the demands placed on the feet, and the
natural history of the underlying disease. Asymptomatic
hypermobile flatfeet in syndromatic children are usually
best left alone (Node 5).
Treatment is based on structural deformity and func-
tional demands placed on the foot. Treatment is usually
indicated if the child is ambulating or likely to become
ambulatory. Children with an unstable base of support
secondary to flatfoot may be treated with supportive
orthoses (Node 7).
Surgical Intervention (Pathway 8, Node 8)
If bracing is not tolerated or does not provide a solid base
of support, surgical intervention may be considered. Surgi-
cal options are aimed at the specific pathoanatomy and
include osteotomies, arthrodesis, arthroereisis, and tendon
transfers. Long-term orthosis management after surgical
intervention is usually recommended to maximize function
(Node 7).
 PATHWAY 8

VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 369

FIGURE 16 Flatfoot deformities in combination with systemic disease and syndromic patterns may be extremely difficult to treat. (A)
Children with congenital myotonic dystrophy show characteristic facial weakness with a cupid bow mouth and inexpressive appearance. (B)
Pronatory foot deformities are a regular feature shown clinically by excessive relaxed calcaneal stance position. (C and D) AP and lateral
radiographs show typical features of severe flatfoot deformity. (E) This is the standing lateral photograph of an 8-year-old with chromosomal
abnormality, showing pronation with equinus. (F and G) The AP and lateral radiographs show complex midfoot and rearfoot coalitions. (H–L)
Shown is a boy with a congenital ball-and-socket ankle with a talonavicular coalition and absence of a lateral ray. Hindfoot instability with
a valgus heel and forefoot abduction are shown clinically and radiographically.

370 THE JOURNAL OF FOOT & ANKLE SURGERY

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