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## Complete Summary

#### GUIDELINE TITLE

Diagnosis and treatment of pediatric flatfoot.

#### BIBLIOGRAPHIC SOURCE(S)

Harris EJ, Vanore JV, Thomas JL, Kravitz SR, Mendelson SA, Mendicino RW,
Silvani SH, Gassen SC. Diagnosis and treatment of pediatric flatfoot. J
Foot Ankle Surg 2004 Nov-Dec;43(6):341-73. \[156 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15605048)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Pediatric flatfoot, including:

-   Flexible flatfoot

-   Rigid flatfoot

    -   Congenital vertical talus

    -   Tarsal coalition

    -   Peroneal spastic flatfoot without coalition

    -   Iatrogenic & post-traumatic

-   Skewfoot

-   Other etiologies of pediatric flatfoot (neurologic or muscular
    abnormalities; genetic syndromes; collagen disorders)

#### GUIDELINE CATEGORY

Diagnosis\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Orthopedic Surgery\
Pediatrics\
Podiatry

#### INTENDED USERS

Physicians\
Podiatrists

#### GUIDELINE OBJECTIVE(S)

To provide recommendations for the diagnosis and treatment of pediatric
flatfoot

#### TARGET POPULATION

Infants, children, and adolescents with known or suspected pediatric
flatfoot

#### INTERVENTIONS AND PRACTICES CONSIDERED

**[Diagnosis]{.underline}**

1.  Comprehensive history and review of symptoms

2.  Assessment of ankle dorsiflexion and plantarflexion and rearfoot,
    midfoot, and forefoot ranges of motion

3.  Gait observation

4.  Radiographs (weightbearing)

5.  Computed tomography (CT)

6.  Magnetic resonance imaging (MRI)

7.  Ultrasound

8.  Bone scans

9.  Laboratory studies, including complete blood count with differential
    and acute phase reactants

**[Treatment]{.underline}**

**Flexible Flatfoot**

1.  Activity modifications

2.  Orthoses

3.  Stretching exercises

4.  Nonsteroidal anti-inflammatory medication

5.  Management of comorbidities

6.  Surgical management

    -   Reconstructive procedures

    -   Arthrodesis

    -   Arthroereisis

**Congenital Vertical Talus**

1.  Manipulation

2.  Serial casting

3.  Orthoses

4.  Closed and open surgical reduction

**Tarsal Coalition**

1.  Footwear modification, arch supports, or custom orthoses

2.  Activity modifications

3.  Weight reduction

4.  Anti-inflammatory medication

5.  Local anesthetic blocks

6.  Cast immobilization

7.  Surgical management

    -   Resection of the coalition in conjunction with osteotomy

    -   Arthrodesis

**Peroneal Spastic Flatfoot without Coalition**

1.  Activity and footwear modifications, arch supports

2.  Immobilization

3.  Supportive orthoses

4.  Peroneal nerve blocks

5.  Surgical management

    -   Arthrodesis

    -   Realignment osteotomy

**Iatrogenic and Posttraumatic Deformity**

1.  Shoe modifications and bracing

2.  Activity modifications, weight reduction, physical therapy, and
    nonsteroidal anti-inflammatory medication

3.  Patient and parent education

4.  Surgical management

    -   Soft tissue release

    -   Osteotomy

    -   Arthrodesis

    -   Distraction osteogenesis (Ilizarov)

    -   Amputation with functional prosthesis

**Skewfoot**

1.  Manipulation

2.  Serial casting

3.  Stretching exercises

4.  Activity modification

5.  Orthoses

6.  Nonsteroidal anti-inflammatory medication

7.  Surgical management

    -   Metatarsal osteotomies

    -   Midfoot osteotomy

    -   Lateral column lengthening, calcaneal displacement osteotomy,
        and tend-Achilles lengthening

**Other Causes of Pediatric Flatfoot**

1.  Supportive orthoses

2.  Osteotomies

3.  Arthrodesis

4.  Arthroereisis

5.  Tendon transfers

#### MAJOR OUTCOMES CONSIDERED

-   Sensitivity and specificity of diagnostic tests

-   Clinical response to treatment

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

This clinical practice guideline is based upon consensus of current
clinical practice and review of the clinical literature.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The recommendations for the diagnosis and treatment of heel pain are
presented in the form of an algorithm with accompanying annotations.
Algorithms are provided for [Pediatric
Flatfoot](http://www.acfas.org/ACFAS_Pediatric_Flatfoot_CPG_1.pdf) (see
page 342 in the original guideline document); [Flexible
Flatfoot](http://www.acfas.org/ACFAS_PedFlatfoot_CPG_Flexible.pdf);
[Congenital Vertical
Talus](http://www.acfas.org/ACFAS_PedFlatfoot_CPG_CongenVertTalus.pdf);
[Tarsal
Coalition](http://www.acfas.org/ACFAS_PedFlatfoot_CPG_TarsalCoalition.pdf);
[Peroneal Spastic Flatfoot without
Coalition](http://www.acfas.org/ACFAS_PedFlatfoot_CPG_PeronSpasFlatfoot_noCoalition.pdf);
[Iatrogenic and Post-Traumatic
Deformity](http://www.acfas.org/ACFAS_PedFlatfoot_CPG_Iatrogen_PosttraumaDeform.pdf);
[Skewfoot](http://www.acfas.org/ACFAS_PedFlatfoot_CPG_Skewfoot.pdf); and
[Other Etiologies of Pediatric
Flatfoot](http://www.acfas.org/ACFAS_PedFlatfoot_CPG_OtherEtiologies.pdf).
Annotations follow.

**[Pediatric Flatfoot (Pathway 1)]{.underline}**

**Significant History (Pathway 1, Node 1)**

Pediatricians and parents often are the first to recognize foot and
ankle pathology in infants and children, but problems 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 treatment, 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, neuromuscular disorders, and structural abnormalities above the
level of the ankle (e.g., 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 from physical activities. Previous treatment may
have modified the clinical presentation. A comprehensive history and
review of systems may show previously unsuspected medical conditions.
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. 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 dorsiflexion and
plantarflexion (with knee extended and flexed) and rearfoot, midfoot,
and forefoot ranges of motion. The forefoot-to-rearfoot relationship is
also assessed. Tenderness 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
contact, position of the knee, and presence of limp.

Diagnostic observations and maneuvers include inversion 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 varum, genu valgum, tibial torsion, femoral torsion, disorders of
muscle tone, and ligamentous laxity that can modify both the natural
history and the severity of flatfoot.

**Diagnostic Studies (Pathway 1, Node 3)**

Imaging options may include radiographs (weightbearing), computed
tomography (CT), magnetic resonance 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 (Pathway
7); and flatfoot caused by other, less frequent causes (Pathway 8). Note
that 4 of these conditions\--vertical talus, tarsal coalition, peroneal
spastic flatfoot without coalition, and iatrogenic/posttraumatic
deformity\--are types of rigid flatfoot.

**[Flexible Flatfoot (Pathway 2)]{.underline}**

**Asymptomatic Flexible Flatfoot (Pathway 2)**

The asymptomatic flexible flatfoot may be physiologic or nonphysiologic
(Nodes 5 and 6). Most flexible flatfeet are physiologic, asymptomatic,
and require no treatment. Physiologic flexible flatfoot follows a
natural history of improvement over time. Periodic observation may be
indicated to monitor for signs of progression (Node 5). Treatment
generally is not indicated.

Nonphysiologic flexible flatfoot is characterized by progression 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
nonphysiologic flexible flatfoot (Node 7). Patients with tight heel
cords may benefit from stretching (Node 8). Orthoses 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 reassessment to identify other underlying
disease.

**Symptomatic Flexible Flatfoot (Pathway 2, Node 6)**

Unlike physiologic and asymptomatic nonphysiologic flexible flatfoot,
symptomatic forms of flexible 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 modifications and orthoses.
Stretching exercises for equines deformity can be performed under
physician or physical therapist supervision. Nonsteroidal
anti-inflammatory medications may be indicated in more severe cases.
Comorbidities, such as obesity, ligamentous laxity, hypotonia, and
proximal limb problems, must be identified and managed, if possible.

If there is a positive clinical response and symptoms are resolved,
observation and orthoses (when appropriate) are instituted. If clinical
response is not satisfactory, reassessment and additional work-ups are
indicated. When all nonsurgical treatment options have been exhausted,
surgical intervention can be considered.

**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 include rearfoot, midfoot, and
forefoot osteotomies. Depending on the plane of dominance of the
deformity, lateral column lengthening 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.

Arthroereisis involves insertion of a spacer into the sinus tarsi for
the purpose of restricting subtalar joint pronation. Proponents of this
procedure argue that it is a minimally invasive technique that does not
distort the normal anatomy of the foot. Others have expressed concern
about placing a permanent foreign body into a mobile segment of a
child\'s foot. The indication for this procedure remains controversial
in the surgical community.

Arthrodesis of the rearfoot has also been described for treatment of
symptomatic flexible flatfoot. Subtalar arthrodesis is typically
performed as the primary procedure. Triple arthrodesis is reserved as a
salvage procedure for previously failed surgical treatment. Although
arthrodesis provides a stable foot and durable correction, eventual
transfer of energy to the nonfused joints adjacent to the fusion is of
concern.

If surgical intervention is successful in producing a functional
painless result, the child should be further treated by periodic
observation and appropriate orthoses. If surgery fails, salvage through
appropriate intraarticular or extraarticular arthrodesis is appropriate.

**[Rigid Flatfoot (Pathway 3 to 6)]{.underline}**

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 associated with underlying primary pathology that can be
diagnosed by clinical and imaging examinations.

The differential diagnosis of rigid pediatric flatfoot includes CVT
(Pathway 3), tarsal coalition (Pathway 4), peroneal spastic flatfoot
without coalition (Pathway 5), and iatrogenic or traumatic joint
pathology (Pathway 6).

**[Congenital Vertical Talus (Pathway 3)]{.underline}**

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, spinal dysraphisms, prune
belly syndrome, de Barsy syndrome, distal arthrogryposis, arthrogryposis
multiplex congenita, congenital metacarpotalar syndrome, Rasmussen
syndrome, and a host of chromosomal abnormalities.

Idiopathic CVT lacks specific etiologic factors. CVT has been associated
with a tarsal coalition. Genetic issues in idiopathic CVT have not been
resolved because of inconclusive data. Results of some studies suggest a
hereditary component, whereas others fail to show patterns of
inheritance.

**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)**

CVT is characterized by a rigid rocker-bottom appearance to the foot.
Pathology findings include dorsal dislocation of the talonavicular
joint, ankle equinus, contracture of the tendo-Achilles, long-toe
flexors, posterior ankle capsule, peroneal tendons, and the anterior
compartment tendons. The tibionavicular ligament is contracted; the
calcaneonavicular (spring) ligament is elongated.

The forefoot is most frequently abducted, but may occasionally be
adducted. The calcaneocuboid articulation often remodels so that the
entire plantar aspect of the foot is convex. Tibialis posterior and the
peroneals may be displaced, the talar head becomes misshapen, and the
deformity is extremely rigid. It is most likely resistant to closed
reduction.

**Diagnostic Imaging (Pathway 3, Node 3)**

Plain radiographs are most often diagnostic. Lateral weightbearing
radiographs show parallelism between the tibia and the talus. The
calcaneus is in equines.

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 reference 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) 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 imaging the deformity
for diagnosis and for surgical planning.

**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 calcaneovalgus deformity, which is flexible, does
not have a rockerbottom configuration, and does not have a talonavicular
dislocation.

**Initial Treatment (Pathway 3, Node 5)**

Initial management of CVT consists of manipulation and serial casting
for approximately 6 weeks. During manipulation, 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. At that point, the equinus may be
corrected by casting. If complete reduction is achieved, an ankle-foot
orthosis can be prescribed (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. If
closed reduction is not successful, open surgical reduction is
necessary. Reduction may be performed in 1 or 2 stages. The benefits and
value of the 2 techniques have been examined by a number of authors.

For infants, the Cincinnati incision gives excellent exposure to the
rearfoot components of the deformity. However, this incision is not
recommended for older children because of concerns about skin perfusion
after this approach. 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.

In older children, the talonavicular joint may be so deformed that
reconstruction is not possible. For these patients, naviculectomy may be
the procedure of choice. The Green-Grice procedure for extraarticular
stabilization may also be used. It may be necessary to consider lateral
column lengthening, osteotomy of the calcaneus, and subtalar arthrodesis
to maintain the corrected position. Talectomy may also be indicated in
selected cases. Tendon transfer for rebalancing is frequently added in
the surgical treatment plan. Continued observation and appropriate
orthosis therapy follows.

**[Tarsal Coalition (Pathway 4)]{.underline}**

Tarsal coalition is a congenital union between 2 or more tarsal bones
that may be an osseous, cartilaginous, or a fibrous connection. The
incidence of tarsal coalition is 1 to 2%. Talocalcaneal and
calcaneonavicular bars are the most common. Talocalcaneal coalitions are
most commonly found at the middle facet. Talonavicular and
calcaneocuboid coalitions also have been described but are much less
common. Autosomal dominant inheritance has been proposed.

**Significant History (Pathway 4, Node 1)**

Tarsal coalitions may be asymptomatic. 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 commonly present in preadolescents or adolescents who suddenly 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.

**Significant Findings (Pathway 4, Node 2)**

Most symptomatic coalitions present with local tenderness 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.

**Diagnostic Imaging (Pathway 4, Node 3)**

Calcaneonavicular coalitions can be seen on both lateral and oblique
radiographs of the foot as an upward and medial prolongation of the
calcaneus toward the inferolateral navicular. Depending on the degree of
ossification of the bridge, there may be a lucent line separating the 2
bones. The 45° oblique plain radiographic view is best for detection of
the calcaneonavicular coalition.

Middle facet talocalcaneal coalitions are difficult to visualize because
of the complexity of the anatomy and because many are cartilaginous. The
lateral radiograph may show the \"C\" or halo sign (the C-shaped line
formed by the medial outline of the talar dome and sustentaculam tali,
which is a secondary sign of a coalition). Harris-Beath projections may
be useful, but they may be difficult to interpret because of problems
with underpenetration. If positive, the articular end plates of the
middle facet are irregular, the facets angulate down and medial, and
there may be partial bridging evident. If angulation is more than 20°,
coalition is probable. Because of the difficulty of interpretation, CT
and MRI studies have largely replaced Harris-Beath projections.

CT is the diagnostic test of choice because of its ability to show the
osseous structures. It is particularly useful for visualizing
talocalcaneal coalitions and for evaluating multiple coalitions. Coronal
images show the location and extent of their involvement.

MRI is particularly useful in evaluating the immature skeleton and in
determining the presence of other causes of peritalar pain. It is
helpful in evaluating fibrocartilaginous coalitions and nonossified
coalitions in the very young.

Bone scans have been used to show increased stresses at articular
surfaces. Bone scans are sensitive but nonspecific.

**Diagnosis (Pathway 4, Node 4)**

Diagnosis of tarsal coalition is based on pain and loss of motion and
supported by appropriate imaging studies. Coalitions are classified by
site, type of interposing tissue, extent of involvement, and secondary
degenerative changes.

**Initial Treatment (Pathway 4, Node 5)**

The initial treatment for any coalition should be nonsurgical. Patients
with mild symptoms may respond well to footwear modifications, arch
supports, or custom orthoses. Activity modifications, weight reduction,
anti-inflammatory medication, and local anesthetic blocks may also be
indicated. Cast immobilization for several weeks may be indicated for
patients with more severe symptoms or with peroneal spasm.

**Clinical Response (Pathway 4, Node 6)**

After a period of nonsurgical treatment, patients should be reevaluated.
If symptoms have been relieved, the initial treatment options should be
continued (Node 7), with periodic observation of clinical progress (Node
8).

**Surgical Intervention (Pathway 4, Node 9)**

Surgical consideration should be given to those who fail to respond to
nonsurgical treatment. Surgical treatment depends on the type of
coalition. Resection of the coalition may be indicated for individuals
without significant deformity or arthrosis. In some cases, arthrodesis
may be the procedure of choice.

In children with foot deformity, osteotomy should be performed in
conjunction with resection. If significant arthritic changes are found,
arthrodesis should be considered. Isolated talocalcaneal arthrodesis is
indicated for subtalar coalitions. If peritalar degeneration is evident,
triple arthrodesis may also be indicated.

Observation and supportive orthoses should follow surgery (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.

**[Peroneal Spastic Flatfoot Without Coalition (Pathway
5)]{.underline}**

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),
its presence cannot be confirmed in a number of cases. Other possible
causes include juvenile chronic arthritis, osteochondral fractures in
the rearfoot, osteoid osteoma, neoplasms, dysplasia epiphysealis
hemimelica (Trevor disease), and problems more proximal in the limb
(slipped capital femoral epiphysis). When no cause can be found, the
condition has been labeled idiopathic peroneal spastic flatfoot.

**Significant History (Pathway 5, Node 1)**

The patient develops pain in the foot, followed by protective limitation
of motion by the extrinsic muscles. Pain is experienced with activity,
and symptoms may be precipitated by trauma. Many patients have been
previously evaluated 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 motion, valgus
appearance of the foot, and constant or intermittent 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 condition such as osteochondral
defect, pathologic fracture through a bone cyst, or osteomyelitis.

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). Elevated 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 supplemented
with nonsteroidal anti-inflammatory 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 below-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 motion, 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)]{.underline}**

Iatrogenic and posttraumatic flatfoot are uncommon and encompass a broad
spectrum of foot disorders. Management can be challenging and complex,
necessitating case-by-case consideration. Surgical treatment of infant
foot deformities often results in undercorrection or over-correction.
This is particularly true for talipes equinovarus. The goal of treatment
is a flexible, plantigrade, painless foot. In many cases, a perfect
outcome is not possible. Often, the end result is a rigid and,
hopefully, plantigrade foot.

Etiologic factors include overcorrected clubfoot, undercorrected
vertical talus, failed flatfoot surgery, and end-stage trauma.
Iatrogenic or posttraumatic flatfoot may also be caused by manipulation
or casting of the pliable, easily damaged infant foot.

**Significant History (Pathway 6, Node 1)**

Patients with iatrogenic or posttraumatic flatfoot present with variable
degrees of pain, loss of function, and progressive 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, abnormal function,
and gait disturbances.

**Diagnostic Imaging (Pathway 6, Node 3)**

Plain radiographs may show postsurgical changes, retained implants and
hardware, malalignment, and arthritis. CT, MRI, and bone scans may be
useful in further defining the deformity and in evaluating residual
pathology.

**Diagnosis (Pathway 6, Node 4)**

The patient\'s history, coupled with diagnostic imaging, confirms the
diagnosis of iatrogenic or posttraumatic flatfoot.

**Initial Treatment (Pathway 6, Node 5)**

Shoe modifications and bracing may be indicated in the initial
management of these deformities. Activity modifications, weight
reduction, physical therapy, and nonsteroidal anti-inflammatory
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)**

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 education should be provided to
encourage realistic expectations.

Soft tissue release, osteotomy, and arthrodesis are the procedures most
frequently used. In certain cases, severe deformities may be realigned
with distraction osteogenesis (Ilizarov). Rarely, in the case of
intractable pain and unstable deformity or chronic osteomyelitis, an
amputation followed by a functional prosthesis is a reasonable 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)]{.underline}**

Skewfoot is characterized by forefoot adduction (metatarsus adductus)
and heel valgus. The more severe cases have midfoot abduction. There are
no universally accepted clinical or radiographic criteria for skewfoot
and the natural history of idiopathic skewfoot is poorly understood.
There are 4 types of skewfoot: congenital idiopathic, congenital
associated with syndromes, neurogenic, and iatrogenic.

**Significant History (Pathway 7, Node 1)**

Skewfoot may be asymptomatic or associated with activity-related pain
and difficulty in fitting shoes. It is often misdiagnosed as metatarsus
adductus and flexible flatfoot. Skewfoot should be suspected if the
infant does not respond favorably to treatment for metatarsus adductus.

**Significant Findings (Pathway 7, Node 2)**

The deformity is characterized as an S- or Z-shaped foot with forefoot
adductovarus and rearfoot valgus. In children younger than 1 year of
age, the rearfoot valgus is not as apparent as the forefoot deformity.
Contracture of the tendo-Achilles may be present. Calluses and other
skin problems may occur.

**Diagnostic Imaging (Pathway 7, Node 3)**

Standard radiographs show metatarsus adductus and severe heel valgus.

**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 treatment (Node 5).
Management of skewfoot is based on age, degree of severity, and presence
of symptoms. Manipulation and serial casting may be indicated for
infants. Stretching exercises and activity modification may relieve mild
symptoms but they will not change the deformity. Orthoses may be used
for symptomatic relief but may exacerbate the symptoms in the presence
of ankle equinus. Nonsteroidal anti-inflammatory medications may also be
beneficial. Management of comorbid conditions is important.

**Clinical Response (Pathway 7, Node 7)**

Clinical response to treatment is evaluated. Observation and
continuation of initial treatment options are recommended 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 forefoot and the rearfoot
components. Useful procedures include metatarsal osteotomies and midfoot
osteotomy to correct the forefoot. Lateral column lengthening, calcaneal
displacement osteotomy, and tendo-Achilles lengthening are used to
correct the rearfoot.

**[Other Etiologies of Pediatric Flatfoot (Pathway 8)]{.underline}**

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 treatment is dependent on the cause. Some have natural
histories that are totally unpredictable, and early intervention is
undesirable until the problem has fully expressed 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, myelomeningocele, developmental delay, genetic diseases,
and other syndromes.

**Significant Findings (Pathway 8, Node 2)**

A variable pattern of foot deformities may be seen. The deformities
range from hypermobile to rigid. Physical examination of these children
must include observational gait analysis, assessment of generalized
joint mobility for hyperlaxity and hypolaxity, and thorough neurologic
examination. 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.

**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 functional 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. Surgical 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).

#### CLINICAL ALGORITHM(S)

Algorithms are provided in Portable Document Format (PDF) in the
original guideline document for:

-   [Pediatric
    Flatfoot](http://www.acfas.org/ACFAS_Pediatric_Flatfoot_CPG_1.pdf)
    (see page 342 in the original guideline document)

-   [Flexible
    Flatfoot](http://www.acfas.org/ACFAS_PedFlatfoot_CPG_Flexible.pdf)

-   [Congenital Vertical
    Talus](http://www.acfas.org/ACFAS_PedFlatfoot_CPG_CongenVertTalus.pdf)

-   [Tarsal
    Coalition](http://www.acfas.org/ACFAS_PedFlatfoot_CPG_TarsalCoalition.pdf)

-   [Peroneal Spastic Flatfoot without
    Coalition](http://www.acfas.org/ACFAS_PedFlatfoot_CPG_PeronSpasFlatfoot_noCoalition.pdf)

-   [Iatrogenic and Post-Traumatic
    Deformity](http://www.acfas.org/ACFAS_PedFlatfoot_CPG_Iatrogen_PosttraumaDeform.pdf)

-   [Skewfoot](http://www.acfas.org/ACFAS_PedFlatfoot_CPG_Skewfoot.pdf)

-   [Other Etiologies of Pediatric
    Flatfoot](http://www.acfas.org/ACFAS_PedFlatfoot_CPG_OtherEtiologies.pdf)

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

This clinical practice guideline is based upon consensus of current
clinical practice and review of the clinical literature.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Accurate diagnosis and treatment of pediatric flatfoot

#### POTENTIAL HARMS

Not stated

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Patient Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Harris EJ, Vanore JV, Thomas JL, Kravitz SR, Mendelson SA, Mendicino RW,
Silvani SH, Gassen SC. Diagnosis and treatment of pediatric flatfoot. J
Foot Ankle Surg 2004 Nov-Dec;43(6):341-73. \[156 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15605048)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 Nov/Dec

#### GUIDELINE DEVELOPER(S)

American College of Foot and Ankle Surgeons - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American College of Foot and Ankle Surgeons

#### GUIDELINE COMMITTEE

Clinical Practice Guideline Pediatric Flatfoot Panel

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Edwin J. Harris, DPM, Chair, Pediatric Flatfoot Panel,
Westchester, IL; John V. Vanore, DPM, Chair, Clinical Practice Guideline
Core Committee, Gadsden, AL; James L. Thomas, DPM, Board Liaison,
Birmingham, AL; Steven R. Kravitz, DPM, Philadelphia, PA; Stephen A.
Mendelson, MD, Pittsburgh, PA; Robert W. Mendicino, DPM, Pittsburgh, PA;
Stephen H. Silvani, DPM, Walnut Creek, CA; Susan Couture Gassen,
Chicago, IL

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American College of Foot and
Ankle Surgeons Web
site](http://www.acfas.org/PediatricFlatfootCPG.html).

Print copies: Available from the American College of Foot and Ankle
Surgeons, 515 Busse Highway, Park Ridge, IL 60068-3150; Web site:
[www.acfas.org](http://www.acfas.org/).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

Information about pediatric flatfoot for patients and parents is
available from the American College of Foot and Ankle Surgeons\' Web
site for patients:
[www.footphysicians.com](http://www.footphysicians.com/info2.php?id=41).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on March 22, 2005. The
information was verified by the guideline developer on May 9, 2005.

#### COPYRIGHT STATEMENT

Please contact the American College of Foot and Ankle Surgeons (ACFAS)
for permission to reproduce.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/10/2008