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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.<ref name="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</ref>,&nbsp;<ref name="2">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</ref>,&nbsp;<ref name="6">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</ref>,&nbsp;<ref name="10">10. A.M. Evans – The paediatric flat foot and general anthoropometry in 140  Australian school children aged 7 – 10 years – 2011  A1</ref>,&nbsp;<ref name="11">11. J.V. Vanore et al – Diagnosis and treatment of adult flat foot  A2</ref><br>
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.<ref name="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</ref>,&nbsp;<ref name="2">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</ref>,&nbsp;<ref name="6">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</ref>,&nbsp;<ref name="10">10. A.M. Evans – The paediatric flat foot and general anthoropometry in 140  Australian school children aged 7 – 10 years – 2011  A1</ref>,&nbsp;<ref name="11">11. J.V. Vanore et al – Diagnosis and treatment of adult flat foot  A2</ref><br>


== Cause  ==
== Clinically Relevant Anatomy ==


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.&nbsp;<ref name="6">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</ref>, <ref name="7">7. Pediatrics – Angela Evans and Ian Mathieson – Elsevier – 2010  A1</ref>&nbsp; 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. <ref name="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</ref><br>
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.&nbsp;<ref name="6">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</ref>, <ref name="7">7. Pediatrics – Angela Evans and Ian Mathieson – Elsevier – 2010  A1</ref>&nbsp; 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. <ref name="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</ref><br>
 
The skeletal framework of each foot is formed by 28 bones: 7 tarsals, 5 meta- tarsals, 14 phalanges and 2 sesamoid bones. From the functional point of view, the feet can be divided in three parts: the hind foot, formed by talus and calcaneus, the midfoot, consisting of navicular, cuboid and three cuneiform bones, and the fore- foot, formed by metatarsals and phalanges. The talus, calcaneus, cuboid, navicular and three cuneiform bones form the tarsus, comprising the hind- foot and midfoot. <br>The hind foot extends from the calcaneal tuberosity to the transverse tarsal joint (Chopart’s joint); the latter consists of the talonavicular part of talocalcaneonavicular joint and the calcaneocuboid joint. The anterior limit can be traced on the surface along the S-shaped line (medially convex and laterally concave) connecting the tuberosity of the navicular bone (palpable inferoanteriorly to the tip of the medial malleolus) with the point located half-way between the lateral malleolus and the tuberosity at the basis of the 5th metatarsal. The movements of the midfoot on the hind foot at the transverse tarsal joint augment the inversion (turning the sole towards the median plane) and eversion (turning the sole laterally), occurring mostly at the subtalar joint. The anterior limit of the midfoot follows the tarsometatarsal joints (Lisfranc’s joint), traced on the surface by the slightly convex line between the tuberosity of the 1st and the prominent tuberosity of the 5th metatarsal bone. These joints allow only slight movement of sliding.
 
<br>The shape of the tarsal and metatarsal bones accounts for the presence of longitudinal and transverse arches of the foot. The medial longitudinal arch extends between the calcaneus and talus (posterior pillar), and first three metatarsal and three cuneiform bones (anterior pillar). The keystone, corresponding to the talar head, is 15-18 mm above the ground. The lateral longitudinal arch is much flatter and rests on the ground in the weight bearing feet. It is composed of the calcaneus (posterior pillar), the lateral two metatarsals (anterior pillar) and the cuboid bone (keystone), which may be 3-5 mm from the ground in the non-weight bearing feet. The transverse arch runs from side to side at the tarsometatarsal joint level. Its medial pillar is represented by the medial cuneiform and the basis of the 1st metatarsal bone, the lateral pillar is formed by the lateral cuneiform, cuboid and the bases of the 3rd-5th metatarsals; the keystone corresponds to the intermediate cuneiform, which can be 18-20 mm above the ground.
 
<br>The arches are passively maintained by plantar aponeurosis and ligaments (long and short plantar ligament, plantar calcaneonavicular ligament) and dynamically supported by tendons of extrinsic muscles (tibialis anterior, flexor hallucis longus and brevis, flexor digitorum longus and brevis for the longitudinal arch; peroneus longus, tibialis posterior for the transverse arch) and by intrinsic muscles that run between the pillars of the arches. These structures act together as a unit to support and distribute appropriately the body weight during walking. (39, level of evidence 2A)<br>


== Classification&nbsp;  ==
== Classification&nbsp;  ==

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Definition/ Description[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

Clinically Relevant Anatomy[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

The skeletal framework of each foot is formed by 28 bones: 7 tarsals, 5 meta- tarsals, 14 phalanges and 2 sesamoid bones. From the functional point of view, the feet can be divided in three parts: the hind foot, formed by talus and calcaneus, the midfoot, consisting of navicular, cuboid and three cuneiform bones, and the fore- foot, formed by metatarsals and phalanges. The talus, calcaneus, cuboid, navicular and three cuneiform bones form the tarsus, comprising the hind- foot and midfoot.
The hind foot extends from the calcaneal tuberosity to the transverse tarsal joint (Chopart’s joint); the latter consists of the talonavicular part of talocalcaneonavicular joint and the calcaneocuboid joint. The anterior limit can be traced on the surface along the S-shaped line (medially convex and laterally concave) connecting the tuberosity of the navicular bone (palpable inferoanteriorly to the tip of the medial malleolus) with the point located half-way between the lateral malleolus and the tuberosity at the basis of the 5th metatarsal. The movements of the midfoot on the hind foot at the transverse tarsal joint augment the inversion (turning the sole towards the median plane) and eversion (turning the sole laterally), occurring mostly at the subtalar joint. The anterior limit of the midfoot follows the tarsometatarsal joints (Lisfranc’s joint), traced on the surface by the slightly convex line between the tuberosity of the 1st and the prominent tuberosity of the 5th metatarsal bone. These joints allow only slight movement of sliding.


The shape of the tarsal and metatarsal bones accounts for the presence of longitudinal and transverse arches of the foot. The medial longitudinal arch extends between the calcaneus and talus (posterior pillar), and first three metatarsal and three cuneiform bones (anterior pillar). The keystone, corresponding to the talar head, is 15-18 mm above the ground. The lateral longitudinal arch is much flatter and rests on the ground in the weight bearing feet. It is composed of the calcaneus (posterior pillar), the lateral two metatarsals (anterior pillar) and the cuboid bone (keystone), which may be 3-5 mm from the ground in the non-weight bearing feet. The transverse arch runs from side to side at the tarsometatarsal joint level. Its medial pillar is represented by the medial cuneiform and the basis of the 1st metatarsal bone, the lateral pillar is formed by the lateral cuneiform, cuboid and the bases of the 3rd-5th metatarsals; the keystone corresponds to the intermediate cuneiform, which can be 18-20 mm above the ground.


The arches are passively maintained by plantar aponeurosis and ligaments (long and short plantar ligament, plantar calcaneonavicular ligament) and dynamically supported by tendons of extrinsic muscles (tibialis anterior, flexor hallucis longus and brevis, flexor digitorum longus and brevis for the longitudinal arch; peroneus longus, tibialis posterior for the transverse arch) and by intrinsic muscles that run between the pillars of the arches. These structures act together as a unit to support and distribute appropriately the body weight during walking. (39, level of evidence 2A)

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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References[edit | edit source]

see adding references tutorial.

  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


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