Guidelines for Evaluation and

Management of Five Common

Podopediatric Conditions
JOHN F. CONNORS, DPM*
ELISSA WERNICK, DPM*
LAURENCE J. LOWY, DPM
JEFFREY FALCONE, DPM
RUSSELL G. VOLPE, DPM

Practice guidelines for five of the most common podopediatric deformities are presented. In establishing these diagnosis and management
guidelines, the authors have reviewed an extensive body of literature
and considered their experience as clinicians in one of the busiest settings for the evaluation and treatment of disorders of childrens feet. No
attempt has been made to be encyclopedic; rather, the authors emphasize practical visual descriptors and the rationale for treatment to
demonstrate the value of early intervention in moderate-to-severe orthopedic pathology of the foot and leg. (J Am Podiatr Med Assoc 88(5):
206-222, 1998)

This article provides readers with a user-friendly,

comprehensive overview of five of the most commonly seen orthopedic foot and leg conditions. It is
intended primarily as a practical guide for those concerned with the diagnosis and treatment of disorders
of the childs foot and leg. It is also intended to serve
as an introduction to management of these disorders
for those who are new to the field of podopediatrics.
The authors, all of whom are faculty members in
the Department of Pediatrics at the New York College
of Podiatric Medicine and clinicians at the Foot Clinics
of New York, have attempted to define, outline both
clinical and radiographic diagnostic criteria for, and

design a logical treatment plan for the following pediatric orthopedic conditions: calcaneovalgus, metatarsus adductus, internal tibial torsion, talipes equinovarus
(clubfoot), and flexible pes valgo planus (acquired
flexible flatfoot).
The articles succinct, schematic style is designed
to facilitate its use as a practical guide and a handy
reference, directing the reader quickly to the essential information needed to diagnose and manage
these conditions appropriately.

*Diplomate, American Board of Podiatric Orthopedics

and Primary Podiatric Medicine; Fellow, American College
of Foot and Ankle Orthopedics and Medicine; Associate Clinical Professor, Department of Pediatrics, New York College
of Podiatric Medicine, 53 E 124th St, New York, NY 10035.
Diplomate, American Board of Podiatric Orthopedics
and Primary Podiatric Medicine; Assistant Clinical Professor,
Department of Pediatrics, New York College of Podiatric
Medicine, New York.
Diplomate, American Board of Podiatric Orthopedics
and Primary Podiatric Medicine; Professor and Chairman,
Department of Pediatrics, New York College of Podiatric
Medicine, New York.

Definition

206

CALCANEOVALGUS

Calcaneovalgus is defined as a congenital flexible

flatfoot deformity usually present at birth. It affects
females more frequently than males, can be unilateral or bilateral, and is present in 1 in 10 live births.
The deformity consists mainly of extreme dorsiflexion of the foot and calcaneal valgus. It is one of the
most common foot deformities. Fortunately, it is generally flexible and has an excellent prognosis if treated early and appropriately.

Journal of the American Podiatric Medical Association

Visual Descriptors

Associated Findings

1. Up and out appearance of the foot.

2. The forefoot is near or touches the anterior aspect
of the ankle and lower leg.

1. The talocalcaneal ligaments are relaxed or absent.12

2. External tibial torsion exists in many cases.5, 12, 13

Rationale for Treatment

1. If left untreated, it may lead to symptomatic flatfoot during childhood and beyond.1-16
2. Severe cases have been associated with congenital
dislocation of the peroneal tendons, which is a
major concern with respect to the developing foot.9
3. Abnormal joint relationships will develop if it is
left untreated during the first year of life.12
4. Ambulation may be delayed because of poor balance. A wider gait angle is needed. Patients have
an outward rotation of the legs and an outward
position of the toes.12
5. If left untreated, it will result in permanent muscle
imbalance (tight dorsiflexors versus lax medial
structures), which may lead to progressive deformity of the bones and joints.1, 10

Diagnosis
Diagnosis is made by both clinical and radiographic
observation. The following criteria should be evaluated, and at least four clinical or two radiographic criteria should be present.
Once a clinician has satisfied the diagnostic criteria, the pathologys severity must be evaluated as per
Grading of Severity.

Clinical Criteria
1. There is excessive dorsiflexion at the ankle and
eversion of the hindfoot, with limited plantarflexion and inversion.
2. The heel has a valgus orientation that can range
from slight to marked eversion.
3. The talar head is palpable both medially and laterally.
4. The foot distal to the midtarsal joint is abducted
and everted.
5. The range of motion of the subtalar joint is normal.
6. The Achilles tendon is not taut, even during complete dorsiflexion.
7. The skin lines around the ankle joint produce
deep creases and furrows anterolaterally and the
skin is extremely taut medially.
8. When plantarflexion is attempted, a deep depression is noted at the sinus tarsi.

Volume 88 Number 5 May 1998

Radiographic Criteria
Lateral View
1. Talar Bisection Line. In a normal foot, the
talar bisection line either bisects the cuboid or passes through the dorsal surface of the bone. In a calcaneovalgus foot, this line falls plantar to the cuboid.
The talus may be markedly plantarflexed.
2. Talocalcaneal Relationship. In a normal foot,
there is no overlap between the talus and the calcaneus. In a calcaneovalgus foot, the talus overlaps the
anterosuperior portion of the calcaneus.
3. Cyma Line. In a normal foot, there is no break in
continuity in the cyma line. In a calcaneovalgus foot,
the line is usually significantly altered by an anterior
break. This indicates a breach in the midtarsal joint.

Dorsoplantar View
The relationship between the talus, navicular, and
first metatarsal is significant. Owing to the cartilaginous structure of the navicular at birth, it cannot be
visualized in a young infant, and the first metatarsal
should be used as a guide.
1. Talar Bisection Line. In a normal foot, the
talar bisection line bisects the first metatarsal shaft.
In a calcaneovalgus foot, the talar bisection line falls
medially outside the foot and does not approximate
the first metatarsal.
2. Talocalcaneal Angle. The normal value for
the dorsoplantar talocalcaneal angle in a newborn is
30 to 40. In a calcaneovalgus foot, the angle is markedly increased.

Grading of Severity
The degree of available plantarflexion at the ankle
and the lateral talar bisection line helps distinguish
the various grades of severity (Table 1).

Treatment
Treatment should begin as early as possible.10-12, 14, 15
Although some authors believe that treatment is unwarranted because the deformity is flexible and
reduces spontaneously during weightbearing,6-8 much
of the literature supports instituting treatment during
the first year of life.1-5, 10-12, 14 Treatment is determined
by the severity of the deformity and whether the
child has begun weightbearing (Table 2).

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Table 1. Grading of Severity of Calcaneovalgus

Clinically

Radiographically

Mild

Can plantarflex to 90 at ankle or slightly beyond

Moderate

Mild moderate: can plantarflex 85 to 90

Severe moderate: can plantarflex 80 to 85

Talar bisection line passes through the lower half of the

lower third of the cuboid

Severe

Plantarflexion is limited to 80 or less

Talar bisection line passes below the cuboid

Talar bisection line passes through the upper half of the

lower third of the cuboid.

Table 2. Treatment for Calcaneovalgus

Infant
(Nonweightbearing)

Infant
(Weightbearing)

Child
(36 Years)

Mild

Manipulation
J strap

High-top shoes
Heel wedges
Longitudinal arch pads

Supportive shoes

Moderate

Tarso Supinator1 shoes,15 bars, and/or

casting, if on the more severe side

Heel wedges
Longitudinal arch pads
High-top shoes
Night splints
Tarso Supinator shoes
Functional foot orthosis

Functional foot orthosis

with medial flange

Severe

Serial mobilization casting until

deformity is resolved,
then night-splint therapy
for a 2- to 10-week course

High-top shoes
Night splints
UCBL/DSIS2 (Dynamic
Stabilizing Innersole
System) orthosis

UCBL/DSIS orthosis
Joint mobilization and rehabilitation
involving intrinsic and extrinsic muscle
groups utilizing strengthening and
stretching exercises

Abbreviation: UCBL, University of California Biomechanics Laboratory.

1
2

MJ Markell Shoe Co, Yonkers, NY.

Langer Biomechanics Group, Deer Park, NY.

METATARSUS ADDUCTUS

Rationale for Treatment

Definition

1. Lack of treatment or undertreatment may result in

hallux valgus, skewfoot, hammer toes, and other
disorders.17-19
2. Treatment can alleviate problems with shoe fitting
later in life resulting from increased rigidity of the
deformity. It can also avoid the deformation of shoes
as well as premature wearing out of shoes.17, 19, 20
3. Significantly, 11% to 14% of cases left untreated do
not resolve.8, 19, 21
4. Treatment can reduce or eliminate tripping and
falling.19
5. Many cases appear clinically improved without
treatment owing to midtarsal joint and rearfoot
compensatory pronation, producing a rectus-looking foot, even though osseous structures are still
deviated, as seen on radiographs. Moreover, the

Metatarsus adductus is defined as a transverse-plane

deformity occurring at Lisfrancs (tarsometatarsal)
joint in which the metatarsals are deviated toward
the midline (medially) of the body. Often, it is associated with internal tibial torsion.

Visual Descriptors
1. Prominent styloid process.
2. C-shaped foot with a concave medial border and a
convex lateral border.
3. Hallux adductus, hallux varus, or both (occasionally).
4. A splay may be noted between the hallux and the
second toe.

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Journal of the American Podiatric Medical Association

increased bulk of the young foot obliterates bony

prominences, giving a straight appearance.22

Diagnosis
Diagnosis may be made by means of at least two of the
following three screening methods. Two are clinical
assessments, and one is a radiographic assessment.

Clinical Assessment
1. V-Finger Test. The V-finger test may be used
as the initial screening tool. In this test, the heel is
placed between the index and middle fingers and the
lateral aspect of the foot is observed for deviation
from the middle finger. Gapping from the finger at
the styloid process of the lateral border of the foot
indicates metatarsus adductus. This test may be used
in cases in which the heel is sufficiently small to be
accommodated in the second interspace of the hand.
With metatarsus adductus, the line extending distally
from the heel falls lateral to the second interspace.
2. Heel-Bisector Angle (Blecks Method).
Another screening tool that may be used is the heelbisector angle. A longitudinal heel bisector is extended distally and its relationship to subsequent toes
and interspaces is noted. Ideally, this line should extend through the second digit and second interspace.

Radiographic Assessment
1. Metatarsus Adductus Angle. The metatarsus
adductus angle is the angle formed by the intersection of the bisector of the second metatarsal and the
transection of the lesser tarsus.
Although the deformity may be diagnosed clinically, in instances when screening tools are questionable, insufficient, or equivocal (eg, when there is difficulty distinguishing metatarsus adductus from talipes equinovarus), radiographs may be obtained and
the metatarsus adductus angle measured. Slight discrepancies in normal values exist,4, 17, 22-24 but significant increases in the angle indicate metatarsus adductus deformity. Normal ranges are as follows:
Birth to 4 months of age:
1 to 3 years:
4 to 6 years:

20 to 30
15 to 20
10 to 15

Volume 88 Number 5 May 1998

2. Talocalcaneal Angle (Kites Angle). The talocalcaneal angle may be used adjunctively to help
distinguish metatarsus adductus from talipes equinovarus. An angle of less than 15 strongly suggests talipes equinovarus.

Grading of Severity
Severity may be assessed clinically or radiographically. As metatarsus adductus is rarely a contested diagnosis, only one criterion is necessary to grade the
severity.

Clinical Assessment
1. Most authors agree that severity should be assessed
clinically as follows:18-21, 25-27
Mild:
Flexible; passively correctable
Moderate: Semiflexible/reducible
Severe:
Rigid
2. Blecks method (modified):
Normal: Heel bisector extends through the
second digit and the second interspace.
Mild:
Heel bisector extends through
the third digit.
Moderate: Heel bisector extends through
the third interspace and the fourth toe.
Severe:
Heel bisector is lateral to the
fourth digit.

Radiographic Assessment
The metatarsus adductus angle should be measured
and assessed according to Table 3. Ontogeny brings a
progressive reduction of the angle; thus values for
children of ages that fall outside the age groups cited
in the table may be interpreted by the practitioner by
extrapolation.

Treatment
Treatment is based on the severity of the condition
and the age of the child (Table 4). While many authors
contend that the deformity spontaneously reduces,
most investigators advocate treatment as soon as
possible, especially in patients with moderate-tosevere cases.5, 8, 17-28

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Table 3. Grading of Severity of Metatarsus Adductus Angle (all values in degrees)

Birth4 Months

13 Years

46 Years

Mild

3140

2125

1620

Moderate

4145

2630

2125

> 45

> 30

> 25

Severe

Table 4. Treatment for Metatarsus Adductus

Birth3 Months
Mild

Observation
Control of sleeping
position

36 Months

612 Months

12 Years

Manipulation

Manipulation
Padded straight-last shoesa

Straight-last shoes
Bracingb

Moderate Manipulation

Serial castingc
Padded straight-last shoesa
Bracingb
Ipos Anti-Adductus Orthosis3

Serial castingc
Bracingb
Possible Ipos Anti-Adductus
Orthosis

If flexible and reducible,

serial casting c
Bracingb
Possible Ipos Anti-Adductus
Orthosis

Severe

Serial castingc
Bracingb
Possible Ipos Anti-Adductus
Orthosis

Serial castingc
Bracingb
Ipos Anti-Adductus Orthosis

Serial castingc; if no
improvement at approximately 2 months,
possible surgery

Serial castingc
Manipulation
Bracingb

Note: Internal tibial torsion frequently accompanies metatarsus adductus, and its presence may influence the choice of
treatment.
a Padding should consist of 1/ -inch felt applied to the medial aspect of the first metatarsal head and along the lateral
4
aspect of the calcaneocuboid joint.
b Bracing may include use of the Ganley splint or Wheaton Bracing System 4.
c All serial casting to be followed by bracing and padding.
3
4

Ipos Orthopedics Industry, Niagara Falls, NY.

Wheaton Brace Co, Carol Stream, IL.

INTERNAL TIBIAL TORSION

Definition
Lower-leg torsion is one of the most common leg
abnormalities seen in infants.5, 29-34 The following terminology is used with respect to this deformity:
Version describes normal variations in limb rotation. Tibial version is the angular difference between
the axis of the knee and the transmalleolar axis.8, 29
Torsion describes version beyond two standard
deviations from the mean and is considered abnormal and described as a deformity.8, 29 A torsional deformity is a twisting about the longitudinal axis.34
Internal tibial torsion is the most common cause
of in-toeing.8, 29, 31 The condition is most often bilateral. Unilateral internal tibial torsion is most common
on the left side.8, 29, 31
Internal tibial torsion is an abnormal increase in
tibial version in an internal direction.29, 35, 36 It is a

210

transverse-plane deformity caused by a fixed structural abnormality occurring in the tibia.2, 29, 30 This
results in an abnormal angle between the knee and
ankle axes for a given patient age. Essentially, there
is a medial rotation of the distal tibia on the proximal tibia.8, 29, 34, 37
The causes of in-toeing from the leg include intrauterine position, angular deformities, compensatory
mechanisms, and iatrogenic complications.29, 31, 38 Intoeing may be caused by a variety of abnormalities of
congenital or acquired origin. It may stem from a
fixed bony deformity, soft-tissue contractures, muscle
paralysis and imbalance, or a change in the planes of
articulation. Internal tibial torsion may have a hereditary basis.

Visual Descriptors
1. Tripping and falling due to internal or adducted
attitude of the feet and legs.

Journal of the American Podiatric Medical Association

2. Internal or adducted attitude of the feet and legs

at rest.
3. Internal or adducted attitude of the feet and legs
during ambulation; usually increased from attitude at rest.2
4. Perceived genu varum beyond what is considered
physiologically normal for a particular age.

Rationale for Treatment

1. Treatment can avoid injuries secondary to tripping and falling.
2. The family history may suggest that the condition
will not be outgrown.29, 39 (If the tibias of the parents and adolescent siblings show normal alignment, the probability of spontaneous correction
by the age of 7 or 8 years is greater. However, if
there is a family history of persistent abnormal
internal tibial torsion, the prognosis for spontaneous correction is guarded, and aggressive therapeutic measures should be considered.)38
3. Treatment can avoid compensatory, pronatory
changes as the child matures, such as increased
abducted gait with breakdown at the midtarsal
joint.4, 29
4. Treatment can reduce muscle fatigue and pain
associated with dynamic muscle imbalance.
5. Treatment can reduce inappropriate joint motion
at the knees.40
6. If left untreated, there may be residual in-toe gait
as the patient matures.
7. Patellar tendinitis and osteoarthritis may develop
owing to compensation.
8. There may be progressive worsening of the condition.40
9. Treatment may result in avoidance of surgery.

Diagnosis
Internal tibial torsion may be diagnosed by means of
one of the following clinical or radiographic criteria.
Diagnosing internal tibial torsion by means of clinical
measures is more common than by means of radiographic measures. Malleolar position provides the
best clinical measure.

Clinical Criteria
Internal tibial torsion is diagnosed clinically by means
of one of the following four criteria. The child should be
observed walking and running during gait evaluations.
1. Foot-Progression Angle. The foot-progression angle is the angular difference between the axis
of the foot and the line of progression. The child is
evaluated during gait.8, 39, 41

Volume 88 Number 5 May 1998

2. Gait Analysis. The principal presenting sign is

an adducted attitude of the foot. There is contactphase adduction of the foot and leg, with adduction
continuous throughout the gait cycle. The leg is internally rotated during swing and the foot plants adducted to the line of progression. This is essentially a nonquantified estimate of the foot-progression angle.8, 39
3. Thigh-Foot Angle. The child is placed in the
prone position with the foot and knee flexed at right
angles.8, 38, 41, 42 The bisection of the thigh and the axis
of the foot (through the second metatarsal) are measured and the difference is noted.
4. Malleolar Position. The child is seated on the
edge of a table with his or her knee flexed 90; the
infant is placed in the prone position and his or her
knee is flexed to a right angle. Through proper positioning of the limb, the tibial transcondylar line (axis
of the knee joint) is made parallel either to the edge
of the table (when sitting) or to the top of the table
(when lying prone). The transmalleolar line (axis of
the ankle) is determined by placing the thumb on the
distal tip of the medial malleolus and the index finger
on the distal tip of the lateral malleolus. The degree
of tibial torsion is determined by the angle formed
between the transcondylar tibial axis and the axis of
the ankle joint (bimalleolar axis).2, 29, 30, 32, 41, 43

Radiographic Criteria
True tibial torsion can be most accurately measured
and diagnosed with radiographs, ultrasound, or computed tomography (CT). However, not all of these
methods are indicated in children, and internal tibial
torsion is most often diagnosed by means of clinical
measures.
With accurate radiography, the actual torsion is
apparent; thus the superiority of this method is obvious. Yet the risk of exposure to radiation often rules
out this diagnostic method for the pediatric population.
The advent of CT and ultrasound has greatly facilitated the measurement of tibial torsion. The use of
CT scans enables the practitioner to measure tibial torsion more precisely than with normal radiographs.44
However, CT scans are expensive and difficult to perform on children. Ultrasound is often preferred over
CT and offers the advantage of a lack of radiation.38
The authors discourage the use of radiographic
interpretation for determination of internal tibial torsion. Clinical interpretation is strongly recommended.

Grading of Severity
The severity of internal tibial torsion may be graded
according to Table 5. Each section of Table 5 repre-

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sents a grading scale based on one of the clinical criteria. Normal clinical values for malleolar position
are given below to serve as guidelines.

The aim of treatment is to prevent internal torsional forces from being applied to the lower extremity and reduce any compensatory mechanisms that
may result from the deformity. The ultimate goal of
treatment is rapid, complete functional reduction of
the problem (Table 6).
There are three different categories of treatment:

Normal Values (Malleolar Position) 5, 29, 30, 43

Birth:
Age 1:

Age 6:

0 to 5 external. Most of the increase in tibial torsion occurs during the first year of life.
5 to 10 external. The tibia externally rotates approximately 2 each year from ages
1 to 6.
13 to 18 external. By age 6, adult values
should be reached.

1. Definitive
a. Serial casting (above the knee). The physician
must cast one joint above the level of pathology.
b. Bracing (CRS5 [Counter Rotation System],
Denis-Browne, Wheaton Bracing System).
2. Cosmetic
a. Twister cables.
b. Gait plates (should be used only if the child has
a propulsive gait).
c. Outer sole wedges.

Treatment
The method of treatment depends on the patients
age, the severity of the deformity, whether excessive
torsional deformities are medial, and the presence or
absence of familial incidence.8, 38
Any significant transverse-plane deviation from
normal values may have an abnormal pronatory effect on the developing childs foot and may either perpetuate an existing pronation abnormality or create
one.45

3. Salvage
a. Tibial rotational osteotomy (indicated only in
the older child [over 8 to 10 years old] who has
significant cosmetic and functional deformity).
5

Langer Biomechanics Group, Deer Park, NY.

Table 5. Grading of Severity of Internal Tibial Torsion (all values in degrees)

Nonambulatory

2 Years

4 Years

According to Foot-Progression Angle

Mild
Moderate
Severe
Asymmetrical

Unable to determine
Unable to determine
Unable to determine
Unable to determine

810
15
> 20
b

6 Years

47
1315
1720
b

03
1012
1517
b

According to Thigh-Foot Angle

Mild
Moderate
Severe
Asymmetrical

03
(2)0
(5)(2)
b

46
04
(2)0
b

79
57
05
b

1013
810
68
b

According to Malleolar Position

Mild
Moderate
Severe
Asymmetrical

(2)5
02
<0
b

57
25
<2
b

810
69
<6
b

1113
10
< 10
b

Note: Numbers in parentheses indicate negative values.

a Values represent internal attitude from line of progression.
b Treatment strongly recommended.

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Journal of the American Podiatric Medical Association

Table 6. Treatment for Internal Tibial Torsion

Nonambulatory

12 Years

> 2 Years

> 6 Years

Mild

Observation
Exercise

Observation
Exercise

Observation
Exercise
Orthoses

Observation
Exercise
Orthoses

Moderate

Serial casting
Exercise
Bracing

Nonambulatory:
Serial casting
Bracing

Gait platesa
Exercise

Gait platesa
Orthoses
Exercise

Outer sole wedge

Gait platesa
Exercise

Orthoses
Exercise

Ambulatory:
Bracing
Outer sole wedge
Exercise
Severe

Serial casting
Bracing

Nonambulatory:
Serial casting
Bracing
Exercise

If conservative
treatment fails,
tibial osteotomy

Ambulatory:
Bracing
Walking cast
Outer sole wedge
Asymmetrical

Serial casting
Bracing

Nonambulatory:
Serial casting
Bracing
Exercise

Outer sole wedge

Gait platesa

Ambulatory:
Bracing
Walking cast
Outer sole wedge
a

Orthoses
Exercise
If conservative
treatment fails,
tibial osteotomy

Gait-plate therapy should be used only if the child has a propulsive gait pattern (heel-to-toe gait).

TALIPES EQUINOVARUS
(CLUBFOOT)

3. Small foot with soft heel and contracted heel

cord.5, 8, 13
4. Heel varus with forefoot adductus.

Definition
Rationale for Treatment
Talipes equinovarus is a congenital foot deformity
that usually consists of four elements:
1. Inversion and adduction of the forefoot.
2. Inversion (varus) of the heel and hindfoot.
3. Equinus throughout both the ankle and the subtalar joint.
4. Internal tibial torsion.

Visual Descriptors
1. Down and in attitude of the foot.
2. May resemble metatarsus adductus.

Volume 88 Number 5 May 1998

Few practitioners would contest the need for treatment of this deformity. Most institute treatment
immediately upon diagnosis, often in the hospital
neonatal unit. Left untreated, the following may
occur:
1. Osteoarthritic conditions may develop in later life
owing to compensatory mechanisms.
2. There may be difficulty in fitting shoes, especially
as the foot becomes less flexible.
3. The patient may suffer ridicule by his or her peers
because of the abnormal appearance of the foot.

213

4. There will be a tendency toward lateral ankle

sprains.
5. Pain may develop on the lateral border of the foot
owing to the shape of the foot and heel-strike
implications.
6. There may be progressive worsening of the condition, especially of the tendo Achillis equinus.

Diagnosis
The diagnosis of clubfoot is not difficult, and the condition is seldom confused with other foot deformities. Sometimes severe metatarsus adducto varus is
confused with clubfoot. However, the equinus component of clubfoot makes the differentiation clear.
Diagnosis may be made by a thorough physical and
clinical examination as well as radiographically.
Clinically, the overall appearance and range of
motion of the affected joints are extremely important.
The following findings indicate talipes equinovarus:

Clinical Criteria
1. Equinus and varus of the hindfoot with adducto
varus of the forefoot and medial rotation.5, 8, 13, 46
2. Small calf compared with the contralateral side.
3. Prominent anterior aspect of the talus on the lateral aspect of the dorsum of the foot.
4. The skin is thinned and stretched on the dorsolateral aspect, with skin creases deeply furrowed on
the medial aspect of the foot.8, 13
5. The lateral malleolus is posterior to and more
prominent than the medial malleolus.
6. During passive dorsiflexion and eversion of the
foot, the tight posterior tibial tendon and triceps
surae can be palpated.
7. Upon palpation, hypertrophied, shortened ligaments and a tight joint capsule will be noted on
the medial aspect of the foot and the posterior
aspects of the ankle and subtalar joints.
8. There is a frequent association with internal tibial
torsion.
Many authors divide talipes equinovarus into one of
the following subtypes.5, 8, 13, 46, 47 Diagnosis based on
these subtypes becomes important for grading of
severity (Table 7).
1. Nonrigid. Known also as postural clubfoot, this
type is a severe positional or soft-tissue deformity;
it is diagnosed when the following features are
present:
a. Manually reducible to 75% to 100% correction
on the transverse, sagittal, and frontal planes.
b. Mild and flexible.2

214

c. The peroneal muscles function when stimulated. Stroking the lateral border causes eversion
and withdrawal from the stimulus.2
d. Normal-sized heel with mild equinovarus attitude of the foot.
e. The lateral border of the foot is convex, with a
normal relationship of the cuboid to the calcaneus. The medial border is concave, with normal skin creases. The forefoot is in slight varus
but not equinus.
f. Mild calf and leg atrophy.
2. Rigid (Moderate)
a. Manually reducible to 50% to 75% correction on
the transverse, sagittal, and frontal planes.
b. The posterior and medial creases of the foot
are more visible than in the nonrigid category.
The lateral border of the foot is more convex,
with the cuboid bone displaced medially, and
the medial border is more concave, with furrowed skin.
c. Peroneal-muscle function is very difficult or impossible to demonstrate.2
d. Smaller-than-normal heel.
e. Calf size and feel are almost normal.
f. Equinus is more dominant than varus, with increased forefoot adduction.
3. Rigid (Severe)
a. Manually reducible to 25% to 50% correction on
the transverse, frontal, and sagittal planes.
b. The foot is extremely stiff and resistant to manipulation.
c. The heel is much smaller than normal.
d. Moderate-to-severe heel varus.
e. The medial border of the foot is very concave,
with deeply furrowed skin. The lateral border
of the foot is very convex, with the cuboid
bone displaced medially over the anterolateral
end of the calcaneus.
f. The calf is tapered and cylindrical with a firm
feel.
g. The attitude of the foot is varus adduction of
the forefoot, equinus, and cavus.
4. Teratologic. This subtype is associated with underlying neuromuscular disorders such as myelodysplasia, arthrogryposis multiplex congenita, spina
bifida, and other congenital deformities.
a. Manually reducible to < 20% correction on the
transverse, sagittal, and frontal planes.
b. Often bilateral.
c. Equinus and varus deformities are extremely
severe.
d. The heel is small, with extreme heel varus.

Journal of the American Podiatric Medical Association

Table 7. Grading of Severity of Talipes Equinovarus (Clubfoot)

Nonrigid
Clinically

Rigid (Moderate)

Rigid (Severe)

Teratologic

75%100% correction
50%75% correction
25%50% correction
Less than 20% correction
with manual reduction
with manual reduction
with manual reduction
with manual reduction
on transverse, sagittal, on transverse, sagittal, on transverse, sagittal, Associated neuroand frontal planes
and frontal planes
and frontal planes
muscular disorder

Radiographically
Anteroposterior:
Talocalcaneal angle ()

2040

1020

< 10

< 10

Lateral:
Talocalcaneal angle ()

3550

2535

< 25

< 25

Radiograph findings
may be normal, but
soft-tissue contractures
may be present

e. The calf feels markedly firm, with an almost

cylindrical, peglike appearance.
f. The skin is atrophied, with a congenital groove
usually present on the inferomedial aspect of
the foot.
g. Thick hyperkeratosis may be present after
weightbearing and during ambulation, especially on the lateral aspect of the foot.
h. The overall attitude of the foot is extreme
varus with equinus. The foot tends to turn inward at a right angle to the leg, with marked
cavus deformity.

Radiographic Criteria
Radiographs are extremely useful in grading severity
and measuring the success of treatment. However, a
standard policy for required x-rays in the treatment
of clubfoot has not been established.13 One of the
problems encountered with radiographs of infants is
that some bones are primarily cartilaginous and,
therefore, angular measurements may be inaccurate.
Another problem is that films are often not taken in a
standardized, reproducible manner (the child cries,
the foot twists, the physicians hands slip). Therefore, x-rays for clubfoot are often used to define patterns rather than clarify details.13
Two of the most common radiographic views
taken are the anteroposterior view and the forceddorsiflexion lateral view. These views can clarify the
relationship between the talus and the calcaneus,
confirming the diagnosis of clubfoot.6, 8, 13, 46 If an
infant is 6 months of age or older, initial radiographs
are useful to supplement the physical examination.2

Volume 88 Number 5 May 1998

Anteroposterior View
1. Talocalcaneal Angle
Normal:
20 to 50 48, 49
Pathologic: Decreased, especially <15
In the normal foot, the long axis of the talus points
medially toward the first metatarsal. The calcaneal bisector points laterally toward the fifth
metatarsal. Both axes form a V. In talipes equinovarus, this talocalcaneal angle is diminished and
may approach 0. In severe cases, the longitudinal
axes of the talus and the calcaneus may become
superimposed and point laterally to the fourth or
fifth metatarsal.5
2. Increased parallelism between the talus and calcaneus is often considered to be pathologic. On the
x-ray this appears as an overlap of the two bones.

Lateral View
1. Talocalcaneal Angle
Normal:
35 to 50
Pathologic: < 35. In severe cases, may reach a
value of 10. 48, 49
2. Forced-Dorsiflexion Lateral View
Normal:
Talocalcaneal angle is increased
during forced dorsiflexion.
Pathologic: Talocalcaneal angle is decreased
during forced dorsiflexion.
The forced-dorsiflexion lateral view is probably
best used for evaluation of the foot during treatment to avoid development of a sagittal-plane
breach (rocker-bottom deformity) or diagnose it
early on.13

215

Treatment
The treatment of clubfoot may require both conservative and surgical care depending on the classifica-

tion and degree of deformity.2 Treatment should be

instituted as early as possible and is based on the
severity of the deformity and the age of the child
(Table 8).

Table 8. Treatment for Talipes Equinovarus (Clubfoot)

Birth1 Year
(Nonambulatory)

12 Years

> 2 Years

Nonrigid

Stretching exercises
Serial immobilization casting
Follow up with Denis-Browne
bar, CRS, Wheaton Bracing
System with high-top
straight-last shoe

Stretching exercises
Consider serial casting
Denis-Browne bar or CRS with
high-top straight-last shoe
as night splint
Physical therapy/muscle
stretching
Prescription shoe, straight or
reverse last
Surgical consultation

Physical therapy
Prescription shoe
Surgical consultation
Custom-fabricated orthoses

Rigid (Moderate)

Serial immobilization casting

Prescription shoe, reverse last
(as a follow-up to casting)
Splint: Denis-Browne bar,
CRS, ankle-foot orthosis
Surgical consultation

Consider serial casting

Prescription shoe, reverse last
Night splint
Denis-Browne bar, CRS, ankle-foot
orthosis
Surgical consultation

Prescription shoe, reverse last

Surgical consultation
Custom-fabricated orthoses

Rigid (Severe)

Surgical consultation
Follow up surgery with serial
casting

Surgical consultation
Follow up surgery with serial casting
Prescription shoe, reverse last,
as a follow-up to surgery
Ankle-foot orthosis, Denis-Browne
bar, CRS as a follow-up to surgery

Surgical consultation
Prescription shoe, reverse last,
as a follow-up to surgery
Ankle-foot orthosis, DenisBrowne bar, CRS as a followup to surgery
Custom-fabricated orthoses

Teratologic

If rigid or nonrigid
(must be assigned a category),
follow previous plan
Underlying etiology must be
addressed by appropriate
medical consultation,
eg, arthrogryposis, muscle
disease, spina bifida, etc.

216

Journal of the American Podiatric Medical Association

FLEXIBLE PES VALGO PLANUS

(ACQUIRED FLEXIBLE FLATFOOT)
Definition
Flexible pes valgo planus is a multifaceted foot deformity described by different authors and practitioners in various ways. The following is a distillation
of the most basic components of the condition as described in the literature. It should be noted that
radiographic evidence of deviations at various joints
can and should be taken into account when defining
the entity.
Flexible pes valgo planus is a flexible foot deformity consisting of an everted or valgus heel with a
decreased medial longitudinal arch during weightbearing. The arch may be normal, low, or absent during nonweightbearing. With weightbearing, there is
abduction of the forefoot on the rearfoot, a decrease
or collapse of the medial column, and eversion of the
calcaneus after heel lift. During gait, the foot or feet
are maximally pronated with little or no resupination. Accentuation of the aforementioned postures
may be evident.
The deformitys reducibility may be based on flexibility. It is frequently associated with generalized ligamentous laxity.

Visual Descriptors
1.
2.
3.
4.
5.
6.

Flatfoot
Fat foot
Floppy foot
The medial malleolus may be abnormally prominent
The medial talar bulge may be evident
The forefoot is abducted on the rearfoot with an
everted heel
7. Too-many-toes sign
8. Out-toe gait

Rationale for Treatment

1. With resultant tendo Achillis contractures, flatfoot leads to disability later in life.50
2. Treatment can avoid surgery necessitated by
hypermobile flatfoot and tight tendo Achillis.
Both hypermobile flatfoot and equinus may lead
to arthritis and pain as the child matures. Both
may be severe and debilitating.8, 50
3. The condition may lead to tarsal tunnel syndrome, with its sequelae and possible need for
surgery.51
4. Treatment can avoid deformation of shoes as
well as premature wear.5, 52

Volume 88 Number 5 May 1998

5. The condition may lead to hallux abducto valgus

later in life.50, 52, 53
6. The condition may lead to joint damage.54-57
7. Flatfoot may lead to foot strain, pain, fatigue, and
leg discomfort in the obese or older child.5
8. Structural changes may occur in the tarsal bones
during adulthood. The deformity may become
rigid.5
9. Adaptive changes in the older child (due to lack
of treatment early on) may preclude the spontaneous correction that some authors believe occurs. The changes often necessitate surgery.58
10. Pediatric patients may experience no symptoms
initially (only a small percentage do), but fatigue,
pain, discomfort, and aching may present later
during adulthood. Symptoms tend to become
more severe with age.11, 50, 59, 60
11. Flatfoot has socioeconomic implications, and
cosmesis should be taken into account.52
12. Flatfoot may cause shoe fitting to become a problem.52, 61
13. Bone and soft-tissue abnormalities have been
exhibited in the untreated flatfoot, including osteoarthritic changes, osteoporosis and osteopenia,
medial soft-tissue swelling, joint damage, and
structural changes of the tarsal bones.56, 57

Rationale for the Use of Orthopedic

Devices in Treatment
1. They extend the wear of shoes, particularly the
heel counter.52 More even shoe wear is achieved.62
2. Heel varus wedges have greatly improved footground patterns, reducing pathologic pressure
beneath the medial longitudinal arch and helping
to correct pronatory forces.54, 63
3. When feet are radiographed within shoes with
orthoses, normal articular relationships are seen,
particularly at the naviculocuneiform and talonavicular joints. Also, calcaneal pitch is restored
or improved.2, 5
4. Orthotic devices have reduced symptoms in athletes, as well as decreased rearfoot pronation and
eversion with respect to speed and amplitude.64, 65
5. Inadequate support of the talus is the basic cause
of flatfoot.50
6. Heel cups and University of California Biomechanics Laboratory orthotic devices have resulted in
improved foot function.66, 67
7. They can decrease symptoms such as anterior tibial muscle pain (shin splints) and diffuse pain as
well as improve gait patterns.62
8. There is decreased stability with a valgus heel.
With the heel realigned (inverted), increased sta-

217

bility of the talonavicular and calcaneocuboid

joints is seen.68 Heel alignment increases the stability of the forefoot.69
9. In the younger child, realignment of the heel and
talonavicular joint results in spontaneous correction.58

Diagnosis
Diagnosis may be based on the following criteria.
These are subdivided into historical, clinical, and
radiographic criteria.

Historical Criteria
1. Wearing out of the medial aspect of the shoe and
the heel.
2. Child walking duck-footed or flatfooted.
3. Patient or parent complaint of ankles touching the
ground or a bone sticking out of the foot medially.
4. Symptomatology such as fatigue and pain.
5. Patient or parent complaint of knees knocking.
6. Patient or parent complaint of bunions.

Clinical Criteria
1. Visual evidence of abduction of the forefoot on
the rearfoot (at the midtarsal joint) with an everted heel.54 Too-many-toes sign present.
2. Evidence of significant decrease in the medial longitudinal arch upon weightbearing.54
3. Plantarflexed or medially deviated talus. When the
patient stands on the toes (or metatarsal heads),
the heel inverts and the medial longitudinal arch
increases.54
4. Increased angle of gait.
5. Increased valgus deformity as measured in relaxed (resting) calcaneal stance position.
6. Helbings sign present.
7. Decreased ankle-joint dorsiflexion.
8. Gait analysis indicating the following (five of the
eight criteria should be met)2, 70, 71:
a. Early heel-off
b. Banana-peel effect (heel lift prior to lateral
forefoot lifting)
c. Decreased or absent resupination
d. Decreased subtalar-joint pronation at heel contact (ie, joint already pronated at heel contact)
e. Medial heel contact
f. Decreased propulsive phase
g. Abductory twist
h. Increased genu valgum beyond what is considered normal physiological development for the
patients age

218

Radiographic Criteria
Flexible pes valgo planus deformity may be diagnosed clinically, but radiographs provide more information about joint integrity and may differentiate the
physiologic fat flat foot of early childhood from
true pes valgo planus.2, 57 Normal and pathologic findings are as follows:
1. Lateral Talometatarsal Angle11, 56, 66, 67, 72, 73
Normal:
0 to 3 (best assessed at > 3 years
of age)56
Pathologic:
> 3
2. Lateral Talocalcaneal Angle 2, 56, 66, 70, 74
Normal:
Birth:
20 to 50
4 to 6 years: 15 to 35
Pathologic:
Increased
3. Dorsal Talocalcaneal Angle 2, 5, 56, 66, 70, 74
Normal:
Birth:
30 to 40
4 to 6 years: 15 to 30
Pathologic:
Increased
4. Talar Declination Angle
(Plantarflexed Talus)5, 50, 54, 66, 73, 75
Normal (birth): 20 to 35
Pathologic:
Increased
5. Calcaneal Inclination Angle (Lateral Calcaneal
Plantar Angle; Calcaneal Pitch Angle)5, 50, 54, 56, 66, 75
Normal:
15 to 30
Pathologic:
Decreased
6. Cuboid Abduction Angle70
Normal:
0 to 5
Pathologic:
Increased
Other angles thought to be significant by various
authors include talonavicular angle5, 11, 70 and naviculocuneiform angle.5, 70

Grading of Severity
The following criteria for various grades of severity
are based on a review of several authors.5, 67, 72, 76 To
effectively grade severity, three clinical or two radiographic criteria should be met.

Mild (Clinical Criteria)

1. Symptomatology: Complaint of fatigue during activity or prolonged standing in a child younger than 3
years old.
2. Relaxed calcaneal stance position70: 2 to 5 everted. Note: Age may be taken into account as per the
Schoenhaus-Jay/Valmassy formula of 8 minus age

Journal of the American Podiatric Medical Association

equals relaxed calcaneal stance position.

3. Longitudinal arch height5: Longitudinal arch depressed but visible with weightbearing.
4. Too-many-toes sign: toes 4 and 5 visible (from
posterior).
5. Gait: Gait analysis is essential in the evaluation of
pes valgo planus.

2. Relaxed calcaneal stance position 70: 6 to 10

everted. Note: The Schoenhaus-Jay/Valmassy formula may be applied.
3. Longitudinal arch height5: Longitudinal arch not
visible with weightbearing.
4. Too-many-toes sign: toes 3 through 5 visible.
5. Gait: Gait analysis is essential.

Mild (Radiographic Criteria)

Moderate (Radiographic Criteria)

Radiographic criteria for a grading of mild are presented in Table 9. Note: Increases in the talometatarsal angle and the cuboid abduction angle should be
considered pathologic regardless of age. The degree
of increase is considered in the grading of severity.

Radiographic criteria for a grading of moderate are

presented in Table 10.

Severe (Clinical Criteria)

1. Symptomatology: Pain with weightbearing or mild
activity (any age). In a child younger than 4 years,
fatigue or a desire to be carried during activities.
In a child older than 4 years, reluctance to participate in sports or weightbearing activities.
2. Relaxed calcaneal stance position70: >10 everted.76 Note: The Schoenhaus-Jay/Valmassy formula
may be applied.

Moderate (Clinical Criteria)

1. Symptomatology: In a child younger than 4 years,
fatigue or a desire to be carried after moderate
activity. In a child older than 4 years, pain with
moderate-to-excessive activity (eg, prolonged
walking, athletic pursuits).

Table 9. Grading of Severity of Flexible Pes Valgo Planus (Radiographically): Mild (all units in degrees)
Birth1 Year

14 Years

> 4 Years

Talar declination angle66, 75

3540

3035

2530

Dorsal talocalcaneal angle

4050

3540

3035

Lateral talocalcaneal angle

5055

4045

3540

Birth2 Years

> 2 Years

Calcaneal inclination angle

510

1015

Talometatarsal angle67, 72

315

315

Cuboid abduction angle

58

58

Table 10. Grading of Severity of Pes Valgo Planus (Radiographically): Moderate (all units in degrees)
Birth1 Year

14 Years

> 4 Years

Talar declination angle 66, 75

4045

3540

3035

Dorsal talocalcaneal angle

5055

4550

3540

5560

4550

4045

Lateral talocalcaneal angle

Calcaneal inclination angle

5, 75

Talometatarsal angle 67, 77

Cuboid abduction angle

Volume 88 Number 5 May 1998

Birth2 Years

> 2 Years

05

510

1530

1530

811

811

219

3. Longitudinal arch height5: Longitudinal arch not

visible, medial border of foot convex with head of
the talus visible.
4. Too-many-toes sign: toes 2 through 5 visible.
5. Gait: Gait analysis is essential.

the individual practitioner must use discretion. However, the suspected long-term effects of lack of treatment for the deformity warrant a bias toward management. The question of whether the symptom-free
child is bound to become the symptomatic adult has
not yet been answered,74 but it appears that many
asymptomatic pediatric flatfeet do progress to painful
deformities during adolescence and adulthood. The
few long-term studies discounting treatment are flawed
at best, usually focusing only on form, not function.
Treatment should be tailored to each individual
situation.78 The age of the patient and the severity of
the flatfoot should be taken into account. Table 12
shows general guidelines culled from several investigators.11, 50, 52, 54, 66, 67, 70, 76, 79-82

Severe (Radiographic Criteria)

Radiographic criteria for a grading of severe are
presented in Table 11.

Treatment
Treatment of flexible flatfoot is one of the most controversial subjects in the orthopedic literature, and

Table 11. Grading of Severity of Pes Valgo Planus (Radiographically): Severe (all units in degrees)
Birth1 Year

14 Years

> 4 Years

66, 75

> 45

> 40

> 35

Dorsal talocalcaneal angle

> 55

> 50

> 40

Lateral talocalcaneal angle

> 60

> 50

> 45

Talar declination angle

Calcaneal inclination angle 5, 75

Talometatarsal angle

67, 72

Cuboid abduction angle

Birth2 Years

> 2 Years

05

> 30

> 30

> 11

> 11

Table 12. Treatment for Pes Valgo Planus

Nonambulatory

13 Years

> 3 Years

Mild

Observation

Oxford shoe or good sneaker

Tarso Supinator shoe with padding

Leather shoe with long counter,
Thomas heel

Moderate

Observation
Possible shoe padding

Tarso Supinator shoe

with padding
Leather shoe with long counter,
Thomas heel
Heel cup or stabilizer
UCBL orthosis

Leather shoe with long counter,

Thomas heel
Padding
Heel cup
UCBL orthosis

Severe

Probable calcaneovalgus:
After casting, monitor
for long-term prognosis

Heel cup
UCBL orthosis

UCBL orthosis
Depending on age, extent of deformity,
and response to conservative treatment, possible surgical evaluation

Note: Padding may consist of appropriate materials applied to the longitudinal arch. The literature supports the efficacy
of heel varus wedges. Physical therapy or exercise should be instituted when the flatfoot is accompanied by soft-tissue contractures.
Abbreviation: UCBL, University of California Biomechanics Laboratory.

220

Journal of the American Podiatric Medical Association

Conclusion
Practice guidelines for five of the most common
pediatric orthopedic deformities have been presented. The definition, etiology, visual description, rationale for treatment, diagnosis, grading of severity, and
guidelines for treatment for each deformity have
been included.
This review has been designed to provide the
reader with a better understanding of these common
pediatric conditions and an improved ability to evaluate and treat them. Early recognition increases the
likelihood of successful management of these deformities. Many of the treatments that are most effective
in producing a normal, functional foot are best instituted before the child begins to walk. Thus it is unfortunate if referrals and consultations are not requested until after children have begun to walk or after
several years with no improvement in the deformity.

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Journal of the American Podiatric Medical Association