Pes Planus

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Search Strategy[edit | edit source]

1. SEARCH STRATEGY ARTICLES


Keywords:

  • Pes valgus physiotherapy (10 results and 3 free full texts): Most successful search
  • Pes valgus (75 results and 4 free full texts) (Elsevier Sciencedirect)
  • Pes planovalgus (23 results and 2 free full texts) (ADB Vubis)
  • Flatfeet children (2 results and 1 free full text) (Elsevier Sciencedirect)


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2. SEARCH STRATEGY BOOKS


Keywords:
• Examination peadiatric foot posture


Via Google Books: Clinical Pediatric Orthopedics

Introduction[edit | edit source]

This text describes pes valgus in children. It is a problem commonly encountered in pediatric orthopedics and is generally considered as caused by the collapse of the medial longitudinal arch in the foot. It was found that 42% of children between 3 and 6 years witch normal weight develop pes valgus. Age, gender, obesity, cerebral palsy, syndrome of Down, … are known risk factors for the development of growth and musculoskeletal changes. Almost 20% of the adult population has pes valgus.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Cause[edit | edit source]

The medial longitudinal arch of the foot normally develops by the age of 5 or 6 as the fat pad in babies is gradually absorbed and balance improves as skilled movements are acquired. In some children however, the arch fails to develop which may be a result of tightness in the calf muscles, laxity in the Achilles tendon or poor core stability in other areas such as around the hips. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title  Over time it may lead to an altered walking pattern, clumsiness, limping after long walks, and pain in the foot, knees or hips. Beside the aforementioned causes for pes valgus, tarsal coalitions, peroneal spasm and vertical talus are common aetiologies during the childhood. It is therefore important that appropriate treatment starts at an early age. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Classification [edit | edit source]

The classification of the pes valgus is based on three aspects.
• Arch height[1], [2]
The best parameter to characterize medial longitudinal arch structure was found to be a ratio of navicular height to foot length. It is accepted that the flatness of normal children’s feet and their age are inversely proportioned.
• Heel eversion angle [3], [4]
Heel eversion or hindfoot valgus is generally accepted as a normal finding in young, newly walking children and is expected to reduce with age. The eversion of the heel has been repeatedly used for determining the posture of the child’s foot.
Resting calcaneal stance position is a more recent method. It has guided clinicians in assessment of the child’s foot posture and calcaneal eversion has been suggested to reduce by a degree every 12 months to a vertical position by age 7 years. A vertical heel is optimal for foot function. The average rear foot angle for children from 6 to16 years is 4° (raging from 0 to 9° valgus).
• Whether the flat foot structure is rigid or flexible (cf. Jack’s test [5])
Rigid pes valgus, also called congenital pes planovalgus (convex) [6], is often a result of tarsal coalition, which is typically characterized as a painful unilateral or bilateral deformity.
In flexible pas valgus, also called congenital pes cancaneovalgus [7], the foot lies against the lower leg, or can be extended without resistance until it impinges against the leg. In contrast to the congenital pes planovalgus, the foot can be restored to a normal position without great resistance. Plantar flexion is occasionally is reduced.


Observation and the development of clinical measures [edit | edit source]

• Footprints  [8]
It is still controversial if footprints reflect the real morphology of the medial longitudinal arch. Recent development found an initial correlation between dynamic pressure patterns and static foot-prints.
• X-rays [9] ,  [10]
X-rays are used to categorize the feet as having normal, slightly flat and moderate arches.
• Foot-posture index (FPI-6)  [11]
It is based on six specific criteria:
1. Talar head palpation
2. Curves above and below lateral malleolus
3. Inversion/eversion of the calcaneus
4. Bulge in the region of the talonavicular joint (TNJ)
5. Congruence of medial longitudinal arch
6. Abduction/adduction of the forefoot en rear foot

• Supination resistance test [12], [13]
This test is used to estimate the magnitude of pronatory moments. The foot is manually supinated. The higher the force required, the greater the supination resistance and the stronger the pronatory forces. This test is subjective.
• Jack’s test and Feiss angle (are related)[14]
Performing the Jack’s test. The hallux is manually dorsiflexed while the child is standing. If the medial longitudinal arch rises due to dorsiflexion of the hallux, the foot is considered a flexible flat foot. If the medial longitudinal arch remains unchanged, the test designates a rigid flat foot. The pupose of this test is to check the foot flexibility and the onset of the windlass mechanism by tensioning the plantar fascia trough the extension of the first metatarsophalangeal joint. The Feiss line is the line interconnecting malleolus medialis, navicular and first metatarsal head. The inclination of this line with the ground increases when the first metatarsophalangeal joint is dorsiflexed (Jack’s test). This dorsiflexion activates forefoot supination and raises the arch height (140°± 6°).
• Ankle range [15], [16]
Children’s ankle range assessment is generally an unreliable measure, as typically assessed when the child is non-weight-bearing.
So it is suggested that therapists look at a child’s ability to squat, heel walk and increase stride length.[17]



Considerations and treatment[edit | edit source]

In some rare cases of pes planovalgus deformity, surgical intervention (arthrodesis) is necessary.[18], [19]
But generally the physiotherapeutic options for the very flat child’s foot may include:
• Advice on appropriate footwear Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, [20]
• Advice on appropriate insoles to improve foot position and referral to an podiatrist and an orthotist: in-shoe wedging, foot splints, night stretch splints and cast orthoses. The primary action splint therapy is aimed at stabilizing the rear foot and midfoot but not blocking the forefoot. Age-expected foot position, stance and gait are dynamic considerations and need to be well understood.[21]
• Reducing pain and risk of secondary joint problems [22] , [23], [24]
• Providing advice on exercise to help stretch tight muscles and strengthen weak areas to aid development of correct foot posture. [25]


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Examination[edit | edit source]

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Medical Management
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1. COCCYGEOPLASTY
By applying the novel techniques that are used in vertebroplasty and sacroplasty, coccygeoplasty is introduced as a new percutaneous treatment modality for fractures of the coccyx. This procedure can be helpful for patients with refractory pain resulting from a fracture of the coccyx and can be performed quickly and safely with high-resolution c-arm fluoroscopy. The coccygeal fracture treated with an injection of polymethylmethacrylate cement can provide early symptom relief. Although the promising results, an experience with a larger patient population is warranted. ( level of evidence C)


2. COCCYGECTOMY
Literature reports suggest that coccygectomy, partial or total removal of the coccyx, has been beneficial with success rates as high as 60-91%. However, coccygectomy is a more invasive procedure, with a common complication rate as high as 22%, and is usually associated with perineal contamination of the wound. Other complications could include persistent bleeding from the hemorrhoidal venous complex of the rectum. (level of evidence C)ix


Physical Therapy Management
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Key Research[edit | edit source]

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Resources
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Clinical Bottom Line[edit | edit source]

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Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

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  1. ↑ 1. K.C. Chen, C.J. Yeh, Li-Chen Tung, J.F. Yang, S.F. Yang, C.H. Wang – Relevant factors influencing flatfoot in preschool-aged children - Springer – 2010  A2
  2. ↑ 5. H. Wetzenstein – The significance of congenital pes calcaneo-valgus in the origin of pes planovolgus in childhood – Orthopaedic department in Jönköping  B
  3. ↑ 3. A. D. Cass, C.A. Camasta - Review of Tarsal Coalition and Pes Planovalgus: Clinical Examination, Diagnostic Imaging, and Surgical Planning – The Journal of Foot and Ankle Surgery – 2010  A1
  4. ↑ 8. G.K. Rose, E.A. Welton, T. Marshall – The diagnosis of flat foot in the child – Britih Editorial Society of Bone and Joint Surgery – 1985  A2
  5. ↑ 7. Pediatrics – Angela Evans and Ian Mathieson – Elsevier – 2010  A1
  6. ↑ 4. H. Wetzenstein – Pes plano-valgus in childhood – Orthopaedic department in Jönköping  B
  7. ↑ 5. H. Wetzenstein – The significance of congenital pes calcaneo-valgus in the origin of pes planovolgus in childhood – Orthopaedic department in Jönköping  B
  8. ↑ 3. A. D. Cass, C.A. Camasta - Review of Tarsal Coalition and Pes Planovalgus: Clinical Examination, Diagnostic Imaging, and Surgical Planning – The Journal of Foot and Ankle Surgery – 2010  A1
  9. ↑ 3. A. D. Cass, C.A. Camasta - Review of Tarsal Coalition and Pes Planovalgus: Clinical Examination, Diagnostic Imaging, and Surgical Planning – The Journal of Foot and Ankle Surgery – 2010  A1
  10. ↑ 8. G.K. Rose, E.A. Welton, T. Marshall – The diagnosis of flat foot in the child – Britih Editorial Society of Bone and Joint Surgery – 1985  A2
  11. ↑ 7. Pediatrics – Angela Evans and Ian Mathieson – Elsevier – 2010  A1
  12. ↑ 3. A. D. Cass, C.A. Camasta - Review of Tarsal Coalition and Pes Planovalgus: Clinical Examination, Diagnostic Imaging, and Surgical Planning – The Journal of Foot and Ankle Surgery – 2010  A1
  13. ↑ 7. Pediatrics – Angela Evans and Ian Mathieson – Elsevier – 2010  A1
  14. ↑ 7. Pediatrics – Angela Evans and Ian Mathieson – Elsevier – 2010  A1
  15. ↑ 3. A. D. Cass, C.A. Camasta - Review of Tarsal Coalition and Pes Planovalgus: Clinical Examination, Diagnostic Imaging, and Surgical Planning – The Journal of Foot and Ankle Surgery – 2010  A1
  16. ↑ 7. Pediatrics – Angela Evans and Ian Mathieson – Elsevier – 2010  A1
  17. ↑ 7. Pediatrics – Angela Evans and Ian Mathieson – Elsevier – 2010  A1
  18. ↑ 2. C.A. Turriago, M. F. Arbela´ez, L.C. Becerra - Talonavicular joint arthrodesis for the treatment of pes planus valgus in older children and adolescents with cerebral palsy – Epos – 2009  A2
  19. ↑ 3. A. D. Cass, C.A. Camasta - Review of Tarsal Coalition and Pes Planovalgus: Clinical Examination, Diagnostic Imaging, and Surgical Planning – The Journal of Foot and Ankle Surgery – 2010  A1
  20. ↑ 7. Pediatrics – Angela Evans and Ian Mathieson – Elsevier – 2010  A1
  21. ↑ 7. Pediatrics – Angela Evans and Ian Mathieson – Elsevier – 2010  A1
  22. ↑ 1. K.C. Chen, C.J. Yeh, Li-Chen Tung, J.F. Yang, S.F. Yang, C.H. Wang – Relevant factors influencing flatfoot in preschool-aged children - Springer – 2010  A2
  23. ↑ 3. A. D. Cass, C.A. Camasta - Review of Tarsal Coalition and Pes Planovalgus: Clinical Examination, Diagnostic Imaging, and Surgical Planning – The Journal of Foot and Ankle Surgery – 2010  A1
  24. ↑ 6. D.J. Oeffinger, R. W. Pectol Jr., C. M. Tylkowski - Foot pressure and radiographic outcome measures of lateral column lengthening for pes planovalgus deformity – Springer – 2009  A2
  25. ↑ 7. Pediatrics – Angela Evans and Ian Mathieson – Elsevier – 2010  A1

MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 451-452, level of evidence D
YU-TSAI T., LI-WEN T., CHENG-HSIU L., SHIH-WEI C., The influence of human coccyx in body weight shifting, medicine and science in sport and exercise, 2011, Volume 43, Number 5, pag. 494-496, level of evidence B
MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 332, level of evidence D
HAARMAN H.J.Th.M., Klinische traumatologie, Elsevier gezondheidszorg, 2006, pag. 117, level of evidence D
MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 461, level of evidence D
TEKIN L. et al., Coccyx fracture in patients with spinal cord injury, European journal of physical and rehabilitation medicine, March 2010, Volume 46, Number 1, pag. 43-46, level of evidence C
RAISSAKI M.T.,Fracture dislocation of the sacro-coccygeal joint: MRI evaluation, Pediatric radiology, March 1999, pag. 642-643, level of evidence D
LONSDALE E.F., A practical treatise on fractures, Walton and Mitchell printers, 1838, pag. 269-270, level of evidence D
MIYAMOTO K. et al., Exposure to pulsed low intensity ultrasound stimulates extracellular matrix metabolism of bovine intervertebral dosc cells cultured in alginate beads, Spine, November 2005, level of evidence B
EBNEZAR J., Essentials of orthopaedics for physiotherapist, Jaypee, 2003, pag. 174, level of evidence D
DEAN L.M. et al., Coccygeoplasty : treatment for fractures of the coccyx, J. Vasc. Interv. Radiol, 2006, pag. 909-912, level of evidence C
COOPER G., HERRERA J.E., Manual of musculoskeletal medicine, Wolters kluwer, Lippincott Williams & Wilkins, 2008, pag. 144, level of evidence D  

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