Flexible Pes Planovalgus (Flexible Flatfoot)

Topic updated on 04/18/16 4:21pm
  • 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
  • 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
  • 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
  • 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
  • Tarsal coalition
  • Congenital vertical talus
  • Accessory navicular
  • 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


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Qbank (3 Questions)

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

1. Talipes equinovarus
2. Cavus foot
3. Flexible pes planovalgus
4. Juvenile hallux valgus
5. Kohler's disease

(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? Topic Review Topic
FIGURES: A   B   C      

1. Lateral calcaneal slide osteotomy
2. Transfer of the peroneus longus to the peroneus brevis
3. 1st metatarsal dorsiflexion osteotomy
4. Calcaneal neck lengthening osteotomy
5. Posterior tibial tendon transfer to dorsum of the foot



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