Foot deformities in pediatrics

Foot Anatomy
• It is divided into 3 main anatomic regions:
1. Hindfoot – talus, calcaneus
2. Midfoot – navicular, cuboid, cuneiforms
3. Forefoot –metatarsals and phalanges

•important joints:
1. tibiotalar (ankle) – plantar/dorsiflexion
2. talocalcaneal (subtalar) – inversion/eversion

• Important tendons:
1. Achilles (post calcaneus) – plantar flexion
2. post fibular (navicular/cuneiform) –inversion
3. ant fibular (med cuneiform/1st met) –dorsiflexion
4. peroneus brevis (5th met) – eversion

Differences between Newborn and Adult foot

Feature Newborn Adult

Arch Flatter, less defined Well defined

Typical ROM Greater ROM Lesser ROM

End point of ROM Soft, difficult to Firm, well defined

appreciate

Amount of subcutaneous Greater Lesser

fat tissue

There are 3 types of deformities:

o Talipes Equinovarus (TEV).
o Talipes Calcaneovalgus.
o Flat feet .
o Pes Cavus Foot (High Arch Foot).
 1. Talipes Equinovarus (TEV)

• Also Called Club foot is a congenital deformity involving one foot or both. The
affected foot appears to have been rotated internally at the ankle.
• It is a relatively common birth defect, occurring in about one in every 1,000 live
births.
• Approximately half of people with clubfoot have it affect both feet, which is
called bilateral club foot

Description of deformity
• It consist of 3 basic components:
i. ankle joint plantarflexed/equines
ii. subtalar joint inverted/varus
iii. forefoot adducted

CLUB FEET CLASSIFICATIONS

1. Congenital clubfoot (CTEV): The most common type.
▪ Etiology:
i. Due to increased intrauterine pressure.
ii. Congenital neuromuscular abnormalities.
iii. Associated with spina bifida that has an L4 or L5 motor level affection.
2. Acquired TEV: Muscle imbalance:
i. Poliomyelitis.
ii. Muscular dystrophy,
iii. Cerebral palsy

Another Classification:
1. Postural (Mobile):
o No bony or joint changes.
o It is commonly of a first or second degree of deformity.
2. Structural ( Rigid):
o Both bony and joint changes, which usually require surgical intervention.

CLUB FEET Muscular Changes

✓ Some muscles become weak due to continuous stretch Proneus tertius

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 ✓ Some muscles become shortened due to their continuous contraction Tibialis
posterior

MANAGEMENT
 Evaluation:
o History taking: Family history, infant birth history and any other anomaly.
o Observation:
1. Shape of the foot: planter flexion, inversion and adduction
2. Size of the foot :smaller than the normal foot
3. If the deformity is unilateral or bilateral.
4. Skin on medial side of foot has wrinkles and on the lateral side
stretched.
5. Toes: big toe abducted away from other toes
6. Small size of the heel.
7. Talus prominent on the dorsum of foot.
o Measurement:
• Passive and active ROM test of the foot
• As well as muscle testing.
• Long measurement: from heel to 2nd toe.
• Round measurement: around the head of metatarsal bone (Heel) in most bulky
area
o Flexibility testing:
The muscles those are liable to shortening
(tibialis posterior and calf muscle).
o Functional test: The child ability to stand and walk

 Treatment: Surgical
Non surgical French method
Ponseti method

Once a child has been diagnosed with clubfoot, treatment should be given
immediately after diagnosis to take full advantage of the flexibility in the baby’s
bones and joints. This allows for improved manipulation to try to achieve a normal
foot.

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 o Aim: To obtain a functional, pain free foot that enables standing and
walking with the sole of the foot flat on the ground.
o Treatment is administrated in 3 stages:
i. Correcting the deformity.
ii. Maintaining the correction until the foot regains normal muscle balance.
iii. Observing the foot several years to prevent recurrence

Non-Surgical Treatment
 French method:
▪ Also known as the "functional method" or "physiotherapy method", is easiest to
do with young bones.
▪ The child's foot is gradually stretched to achieve the right position, being held in
place with tape after stretching TO maintain ROM, after taping Plastic Splint is put
on over the tape to maintain the improved ROM.
▪ Daily method : 3 times / week by PT and other days by family.
▪ After 3 months, Achilles tenotomy may be done to improve dorsiflexion of the
ankle.
▪ To prevent recurrence of the clubfoot, the daily regimen of stretching, taping and
splinting must be continued by the family until the child is 2 to 3 years old

 Ponseti method:
1. Manipulation and casting:
▪ Gentle stretch and manipulation into a corrected position and holding in place
with along leg cast ( toes to thigh) for 6 to 8 weeks.
2. Achilles tenotomy:
▪ Most babies will require a minor procedure to release continued tightness in the
achilles tendon
▪ A new cast will be applied to the leg to protect the tendons as it heals for 3
weeks.
3. Bracing:
▪ Even after successful correction with casting, club feet have a natural tendency to
recur.
▪ Boots and bar will be wearied for a few years.

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 ▪ The brace keeps the foot at the proper angle to maintain the correction. This
bracing program can be demanding for parents and families but is essential to
prevent relapses.
For the first 3 months, your baby will wear the brace essentially full-time (23 hours
a day). Your doctor will gradually decrease the time in the brace to just overnight
and nap time (about 12 to 14 hours per day). Most children will follow this bracing
regimen for 3 to 4 years.

Examples of a solid bar brace. (Left) The Markell Abduction Brace. The Dobbs Dynamic Abduction
(Right) Brace.
TheMitchell Abduction Brace.

Physical Therapy
 Stretching Exercises:
▪ Some authors suggested correction of equines deformity before inversion.
▪ Others suggested correction of all the three components of deformity
simultaneously.
 Manipulation:
▪ The knee joint must be held flexed to avoid strain on the medial ligament of the
knee and the foot is kept outside the plinth.
▪ Vigorous mobilization leads to break midtarsal joints or damage soft tissues
around foot.
 Electrical Stimulation:
▪ Faradic stimulation is applied for anterior tibial group:
✓ One electrode is placed over lateral aspect of leg on fibular head.
✓ Another electrode is placed on front of ankle joint.
✓ 10 min of FS 3 times / week.
 Hydrotherapy:
▪ Cold pack and therapeutic exercises to relieve pain.
▪ Hubbard tank is used to:

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 1) Reduce pain
2) Apply mobilizing exercises.
3) Gait training.
 Active exercises:
▪ To correct the deformity and prevent muscle weakness and wasting.
 Postural Exercises:
▪ Standing exercise will help postural adjustment of the leg and foot.

Surgical Treatment
• Although many cases of clubfoot are successfully corrected with nonsurgical
methods, sometimes the deformity cannot be fully corrected or it returns, often
because parents have difficulty following the treatment program. In addition, some
infants have very severe deformities that do not respond to stretching. When this
happens, surgery may be needed to adjust the tendons, ligaments, and joints in the
foot and ankle.
• Less extensive surgery will target only those tendons and joints that are
contributing to the deformity. In many cases, this involves releasing the Achilles
tendon at the back of the ankle or moving the tendon that travels from the front of
the ankle to the inside of the midfoot (this procedure is called an anterior tibial
tendon transfer).
• Major reconstructive surgery for clubfoot involves extensive release of multiple
soft tissue structures of the foot. Once the correction is achieved, the joints of the
foot are usually stabilized with pins and a long-leg cast while the soft tissue heals.
• After 4 to 6 weeks, the doctor will remove the pins and cast, and typically apply a
short-leg cast, which is worn for an additional 4 weeks. After the last cast is
removed, it is still possible for the muscles in your child's foot to try to return to
the clubfoot position, so special shoes or braces will likely be used for up to a year
or more after surgery.
• The most common complications of extensive soft tissue release are
overcorrection of the deformity, stiffness, and pain.

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 2. Talipes Calcaneovalgus

• Description of deformity:
1. Dorsiflexion of ankle joint.
2. Eversion of subtalar joint.
3. Abduction of midtarsal joints.

• Muscular Changes
✓ Some muscles become weak due to continuous stretch Tibialis posterior
✓ Some muscles become shortened due to their continuous contraction Proneus
tertius`

Most cases of talipes calcaneovalgus feet spontaneously resolve within the first
year during walking do not need treatment
With no improvement, treatment is recommended ( Exercises includes
strengthening to weak muscle “tibialis posterior” and stretching to tight muscle
“prenous tertius” ,corrective shoes or casting)

Physical Therapy
 Stretching and mobilization exercises to correct the deformity.
 Strengthening exercises for planter flexors and invertors ( Tibialis posterior).
 Electrical stimulation.
 Ice application as a stimulating technique.
 Splinting to correct foot position.

3. Flat feet
•Alternative names:
 Pes planus.
 Fallen arches.
 Pes planovalgus,
 Pronation of feet.

• Foot Arches:
1. Longitudinal arch:

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  Medial Longitudinal arch: supported by spring ligament and tibialis
posterior.
Assist in propulsion of body forward during walking and running.
 Lateral Longitudinal arch: supported by planter ligament and peroneus
longus
Assist in support body weight during standing.
2. Transverse arch: supported by interossei ligament
❖ Factors supporting the arches:
i. The shape of foot bones
ii. Activity of the muscles
iii. A wide variety of ligaments and tendons of the muscles acting as ligament.

• Flat feet (pes planus) refer to a change in foot shape in which the foot does not
have a normal arch when standing.
• Babies are often born with flat feet, which may persist well into their childhood.
This occurs because children’s bones and joints are flexible, causing their feet to
flatten when they stand. Young babies also have a fat pad on the inner border of
their feet that hides the arch.
• Normally, flat feet disappear by age six as the feet become less flexible and the
arches develop. Only about 1 or 2 out of every 10 children will continue to have
flat feet into adulthood.
• Most children with flatfoot have no symptoms, but some children have one or
more symptoms. When symptoms do occur, they vary according to the type of
flatfoot.

• Some signs and symptoms may include:

1) Pain, tenderness, or cramping in the foot, leg, and knee.
2) Awkwardness or changes in walking
3) Difficulty with shoes
4) Reduced energy when participating in physical activities
5) Voluntary withdrawal from physical activities.

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 • Flatfoot can be apparent at birth, or it may not show up until years later,
depending on the type of flatfoot. Some forms of flatfoot occur in one foot only,
while others may affect both feet

• Types of Pediatric Flatfoot :

1) Asymptomatic (without symptoms)
As mentioned earlier, the majority of children with flatfoot have an asymptomatic
condition.
2) Symptomatic (with symptoms):
Symptomatic flatfoot is further described as being either flexible or rigid.
▪ “Flexible“means that the foot is flat when standing (weight bearing), but the
arch returns when not standing.
▪ “Rigid” means the arch is always stiff and flat, whether standing on the foot or
not

• Several types of flatfoot are categorized as rigid. The most common are:
I. Tarsal coalition: This is a congenital (existing at birth) condition. It involves an
abnormal joining of two or more bones in the foot. Tarsal coalition may or may
not produce pain. When pain does occur, it usually starts in preadolescence or
adolescence.
II. Congenital vertical talus: Because of the foot’s rigid “rocker bottom”
appearance that occurs with congenital vertical talus, this condition is
apparent in the newborn.
Symptoms begin at walking age, since it is difficult for the child to bear weight and
wear shoes.

• Diagnosis :
In diagnosing flatfoot, the foot and ankle surgeon examines the foot and observes
how it looks when child stands and sits.
The surgeon also observes how the child walks
Evaluates the range of motion of the foot.
Because flatfoot is sometimes related to problems in the leg, the surgeon may
also examine the knee and hip.
X-rays are often taken to determine the severity of the deformity.

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• Treatment:
I. Asymptomatic type:
▪ Non-surgical Approaches If a child’s flatfoot is asymptomatic.
▪ Treatment is often not required. Instead, the condition will be observed and
reevaluated periodically by the foot and ankle surgeon.
▪ Custom orthotic devices may be considered for some cases of asymptomatic
flatfoot.
II. Symptomatic type:
In symptomatic pediatric flatfoot, treatment is required. The foot and ankle
surgeon may select one or more approaches, depending on the child’s particular
case.
• Some examples of non-surgical options include:
1) Activity modifications:
The child needs to temporarily decrease activities that bring pain as well as avoid
prolonged walking or standing.
2) Orthotic devices:
The foot and ankle surgeon can provide custom orthotic devices that fit inside the
shoe to support the structure of the foot and improve function.
3) Physical therapy:
Stretching exercises, supervised by a physical therapist, provide relief in some
cases of flatfoot.
4) Medications:
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be
recommended to help reduce pain and inflammation.
5) Shoe modifications:
The foot and ankle surgeon will advise you on footwear characteristics that are
important for the child with flatfoot

• Exercises and activities for flexible flatfoot

Aim Exercises and activities

Flexibility Passive ROM exercise of ankle and all foot joints Global
movement (to approximate anterior and posterior foot

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 columns)
Stretching of gastrocnemius soleus complex and peroneus
brevis muscles (to induce varus and adduction of the foot).

Strengthening Anterior and posterior tibialis muscles and the flexor hallucis
longus (to neutralize valgus) Intrinsic, interosseus plantaris
muscles and the abductor hallucis (to prevent anterior arch
flattening) Global activation/movement of the muscles
involved in maintaining the medial longitudinal arch and the
varus with and without load Single leg weight bearing Toe
walking

Proprioception Toe and heel walking Single leg weight bearing (to make the
and balance foot cavus after dynamic pronation of the forefoot)
Descending an inclined surface

4. Pes Cavus Foot (High Arch Foot)

• Alternative Names:
o High instep.
o High arch.
o Talipes cavus.
o Cavoid foot.
o Supinated foot
• Etiology:
Pes Cavus refers to a foot that has an arch that is higher than normal.
• Symptoms/Signs:
Shock absorption is poor, thus problems includes:
1) General foot pain
2) Metatarsalgia
(pain in the ball of the foot or under 2nd or 3rd metatarsal head),
3) Hammer toes.
• Management:
If problems occur, orthotic should be constructed using lateral wedge.
Stretching of the Achilles tendon and the plantar fascia is helpful

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