Pediatric Foot Alignment Deformities

What is Pediatric Foot Alignment Deformities?

Pediatric foot alignment deformities refer to a variety of conditions affecting the structure and position of a child’s foot. These conditions can either be simple or complex, appearing at birth or later in life, or in some cases, even before birth. Parents typically seek medical advice for their children with these conditions.

The most common forms include clubfoot, flatfoot (also known as planovalgus foot), cavovarus foot (high-arched foot with a turned-in heel), congenital vertical talus, congenital oblique talus, metatarsus adductus (a foot that turns inward), and skew foot deformity.

Clubfoot is a fairly common foot deformity present at birth that can result in severe disability if not treated. The deformity consists of four components: high arch (Cavus), foot turning inward (Adductus), heel turning inward (Varus), and ankle pointing down (Equinus). If treated early, children with clubfoot usually do well, with the Ponseti method of casting being a common treatment.

Flatfoot, also referred to as pes planovalgus deformity, is a common condition in adolescents characterized by a flat midfoot and an inward-turned heel (valgus deformity). Diagnosis is often clinical, although imaging tests might be used to rule out other conditions.

Cavovarus, or high-arched foot, is another common condition in children and adults marked by a high arch and inward-turned heel. It is generally associated with neurological disorders or trauma. Treatment options vary from shoe inserts (orthotics) to surgery.

Congenital vertical talus (CVT) is a rare condition which results in a rigid flatfoot deformity, usually caused by chromosomal or neuromuscular abnormalities. If not treated properly, CVT may lead to significant disability.

Congenital oblique talus (COT) is an uncommon foot deformity similar to CVT but may be considered a normal variant of foot structure.

Metatarsus adductus is the most common foot deformity in newborn babies, leading to the foot turning inward at the joint between the toes and the rest of the foot. The cause isn’t fully known, however, most cases naturally resolve by the child’s first birthday.

Skew foot is a rare foot deformity characterized by the front part of the foot turning inward, the middle part turning outward, and the heel pointing outwards, forming a “z” shape. The causes can be both congenital (present at birth) or acquired, and treatment usually involves surgery.

What Causes Pediatric Foot Alignment Deformities?

The reasons for foot deformities can be varied, including genetic and environmental factors.

The root cause of clubfoot is mostly unknown, but both genetic and environmental factors can play a role. If a baby is born with clubfoot, there’s about a one in four chance that the family has a history of the condition. Some genes have been identified that may contribute to clubfoot, including the HOX gene that affects muscle contraction, and the PITX1-TBX4 pathway that’s important for limb development.

Most of the time, clubfoot is a standalone issue, but about one in five times, it can show up along with various genetic syndromes and medical conditions. Conditions like arthrogryposis, myelodysplasia, and others have been linked to clubfoot. Also, factors like smoking during pregnancy, maternal diabetes, and low amniotic fluid levels have been connected to clubfoot. In some studies, it has been suggested that factors such as paternal smoking, maternal obesity, use of certain antidepressants, first pregnancy, exposure to alcohol or solvents may be linked to a higher risk of clubfoot.

Pes planovalgus or flat foot can be present from birth or develop as a result. It’s common in young children but usually corrects itself by about age 5 when children start to walk on their toes. Factors like being overweight can contribute to the development of flatfoot. Acquired flatfoot can occur after an injury or due to certain genetic syndromes, such as Down syndrome, Marfan, or Ehlers-Danlos syndromes. This is usually due to malfunction of the posterior tibialis muscle and laxity.

Pes cavovarus or high-arched foot is usually linked to neurological or traumatic conditions but can also occur on its own. Conditions such as cerebral palsy, amniotic band syndrome, and Friedreich’s ataxia are often associated with this deformity. Charcot-Marie-Tooth disease is usually the most common cause in patients with bilateral deformity. In cases where only one foot is affected, conditions such as brain tumors or tethered spinal cord should be ruled out.

Congenital vertical talus, where the sole of the foot faces upwards, though the exact cause is unknown, it’s often associated with chromosomal, musculoskeletal, or neurologic conditions. Conditions often linked with this deformity are arthrogryposis, myelomeningocele, and cerebral palsy. A positive family history may be present, and mutation in the HOXD10 gene, important for limb development, has also been noted.

Congenital oblique talus, where the foot rotates outwards, though the exact cause is unknown, conditions such as cerebral palsy or Down syndrome are often associated with it.

Metatarsus adductus, where the front of the foot is turned inward, is thought to be caused by increased pressure in the womb, particularly in twins, abnormalities in the bones, or abnormal muscle attachments. However, the exact cause is still debated.

Skew foot, where the foot twists at an angle, can either be present at birth or develop later. Occurrence after metatarsus adductus has been seen. However, the exact cause is unknown but can be due to muscle imbalances. It can be categorised into four types: idiopathic congenital skew foot; skew foot associated with syndromes, like osteogenesis imperfect; skew foot secondary to neurological conditions, like cerebral palsy or myelodysplasia; and iatrogenic skew foot (develops after treatment for clubfoot or metatarsus adductus).

Risk Factors and Frequency for Pediatric Foot Alignment Deformities

Epidemiology, or the frequency and patterns of health issues in different populations, varies for each type of foot deformity. Here’s a simple breakdown:

• Clubfoot: This is the most commonly reported birth defect of the limbs, with about 1 case per 1000 live births. It’s more common in certain populations like Hawaiians and Maori. Men are twice as likely to be affected. Half of the cases are on both feet, while in single-foot cases, the right foot is usually the one affected.
• Planovalgus: The frequency in children isn’t known. In adults, between 13.6% and 37% have this condition.
• Cavovarus: The frequency of this deformity is largely unknown. About 10% of the general population are said to have this condition. It’s mostly associated with neurological conditions. For example, in a study of 148 children with a bilateral cavovarus foot deformity, 78% were linked with Charcot-Marie-Tooth syndrome, and this rose to 91% for those with a family history of the syndrome. Another study found a 25% prevalence of these deformities in 1047 diabetic cases.
• Congenital vertical talus (CVT): CVT is rare and occurs in almost 1 in 10,000 live births.
• Congenital oblique talus (COT): The frequency of COT is unknown.
• Metatarsus adductus: This happens in 1 to 2 births per 1000. It’s more common in women, and about 50% of cases affect both feet.
• Skew foot: The frequency is largely unknown. However, about 0.5% of children are said to have this condition.

Signs and Symptoms of Pediatric Foot Alignment Deformities

For diagnosing foot deformities, doctors rely on medical and family history, physical examinations, and in some cases, neurological testing or genetic testing. Below are specific details related to different types of foot deformities:

• Clubfoot: Checks include family, pre-birth, and birth history, including instances in the family and any exposure to risk factors like smoking, medication, and alcohol. On examination, the foot assumes a distinct position. Depending on the severity, the limbs may be of different lengths. Clubfoot can sometimes be part of syndromes and medical conditions.
• Planovalgus: A medical history check is made to understand if the flat foot condition is congenital or acquired. Symptoms may include pain around the sole of the foot and unstable ankles. The physical exam focuses on posture, flexibility, and walking pattern.
• Cavovarus: History and physical checks are carried out to examine potential causes. The condition may present as chronic foot pain, or unstable ankles. A neurological exam is conducted to potentially alter the course of treatment.
• Congenital Vertical Talus: Comprehensive medical and family history is taken into account. On examination, it may appear as a ‘rocker-bottom’ deformity. Neurological checks are a crucial part of the evaluation.
• Congenital Oblique Talus: Thorough history and physical checks are considered. In severe cases, forefoot may be facing upwards while the hindfoot tilts outwards and downwards. A complete neurological check is essential.
• Metatarsus Adductus: Detailed history is taken, as the condition may co-exist with other ones. Physical examination includes a series of tests and methods to evaluate the condition.
• Skew Foot: Medical past and family history are evaluated to identify secondary causes. The physical exam involves an examination of the foot from various aspects including top and bottom views.

Understanding the specifics of each deformity assists in identifying the correct treatment and potential causes behind them.

Testing for Pediatric Foot Alignment Deformities

If your child has a foot deformity, it’s usually diagnosed with a physical examination. However, X-ray imaging can also help confirm the diagnosis and aid in planning any necessary surgeries. The most standard way of doing a foot X-ray involves the child standing or pretending to stand while pictures are taken of the foot from the front and the side. Non-weight-bearing X-rays can sometimes be misleading, so it’s best to approach those with caution. In complex cases, or when more detail is needed, your doctor might order a CT scan or an MRI, which give more detailed pictures of the foot’s structure.

In a normal foot, the talus bone (located near the top of the foot) is held in place at the ankle. It’s essential for the correct alignment and movement of the foot. In certain foot deformities, the talus and other foot bones can deviate from their normal alignments, which can be seen in X-ray images.

Clubfoot is usually diagnosed with a physical examination rather than an X-ray, and it can sometimes be spotted before birth with an ultrasound. However, X-rays can still be helpful for confirming the diagnosis. The bones in a clubfoot often appear more parallel to each other in X-rays, which is different from their normal alignment.

Planovalgus or flatfoot, although usually diagnosed clinically, may need further evaluation in some cases. For instance, if there are symptoms of pes cavovarus (a high-arched foot with turned-in heel), X-rays may be necessary to rule out other foot problems. X-rays may also be performed in case of rigid flatfoot. Certain angles measured on the X-ray will be different from normal if flatfoot is present.

For cavovarus foot, diagnosis is also primarily clinical. However, an X-ray often shows a decreased angle between the talus and calcaneus, indicating varus deformity. The angle between the talus and first metatarsal bone will also be greater than normal, indicating a high arch. Specific sign is indicative of cavus deformity.

Congenital vertical talus, congenital oblique talus, and skew foot are other foot conditions that do require specific X-rays for diagnosis. These deformities result in abnormal alignment of bones and joints in the foot. Certain conditions like these might need further testing to rule out possible associations with neurologic or genetic conditions, which could involve MRI scans, nerve conduction studies, or genetic testing.

Metatarsus adductus, or having the front half of the foot turned inward, is diagnosed primarily by physical examination in children. X-rays aren’t usually very helpful for this condition, particularly in young children, due to the lack of full bone development in the foot. The severity of metatarsus adductus is determined by observing the alignment of the foot, and flexibility is tested for too.

As almost two-thirds of foot deformities in children are associated with a neurological condition, most commonly Charcot-Marie-Tooth disease further studies are usually required – such as genetic testing and nerve signal testing (electrodiagnostic studies) – to establish the cause of the deformity.

Treatment Options for Pediatric Foot Alignment Deformities

Foot deformities can occur in various ways, and the treatment can range from simple watchful waiting and reassurance to the use of shoe inserts or plaster casts, and in more severe cases, surgeries may be needed. Let’s look at some different types of foot deformities and how doctors approach them.

Take Clubfoot for instance, the preferred treatment is the Ponseti method in which plaster casts are applied weekly, starting within the first two weeks after birth. This method involves a step-by-step correction of different parts of the foot. Most patients also need a lengthening procedure called Tendoachilles lengthening after 8 weeks. Following this, a foot abduction orthosis (a type of foot brace) should be worn until the child is 4 years old. In some cases, other surgeries or procedures may be required. An alternative method involves daily manipulation and physical therapy, but this is not as commonly used. For persistent clubfoot deformities, various surgical options may be necessary.

Planovalgus deformities, on the other hand, usually require more conservative management, especially in children where it’s usually temporary. In adults, the management depends on what caused the deformity. This can involve stretching, modification of footwear, and heel support with orthotics. If these methods fail to alleviate symptoms, surgery may be considered.

For Cavovarus deformities, foot orthotics can be used for mild cases or as temporary measures before or after surgery. However, surgery is often the best approach for cavovarus, with different types of procedures being used depending on the specific nature of the deformity.

Congenital Vertical Talus, a rare form of flatfoot present at birth, usually requires surgery to allow the patient to walk properly. The surgical treatment typically involves initial application of long-leg serial casts, followed by surgeries that address the specific abnormalities in the foot. It is important that treatment is carried out before the age of 2 for the best results.

As for Metatarsus adductus, which is a foot deformity where the front half of the foot, or forefoot, turns inward, most mild cases are relieved spontaneously before the age of one. However, severe and rigid cases may require interventions such as the use of shoe inserts, plaster casts, or even surgery.

The treatment of skew foot, a rare combined deformity of the foot, is largely determined by the severity of the deformities and the age at diagnosis. This can involve using serial long-leg casts with hindfoot valgus molding. If these measures fail, multiple surgeries may be required on the forefoot, midfoot and hindfoot. Surgery in this case is usually postponed until after the age of 6 because all components of the foot need correction.

In all cases, it’s important to understand that the type, severity and cause of foot deformity determine the appropriate treatment approach. This can range from observation to shoe inserts to multiple surgeries, making it the doctor’s job to identify the perfect fit for the patient’s specific needs.

What else can Pediatric Foot Alignment Deformities be?

Kids’ foot problems might seem similar and can be confused with other conditions. Therefore, it’s key to understand how each condition is unique. Here’s a breakdown:

• Clubfoot: Clubfoot is easily recognized and is hard to confuse with other foot problems. However, it’s crucial to rule out other birth defects of the foot like congenital vertical talus or calcaneovalgus.
• Planovalgus: Diagnosing Planovalgus is more straightforward. It’s important to distinguish it from having a noticeable arch fat pad and also from tarsal coalition, a condition that can cause rigid flat feet.
• Cavovarus: Cavovarus foot, a condition where the foot has a higher-than-normal arch, needs to be differentiated from equinovarus foot.
• Congenital vertical talus: Here, it’s essential to distinguish it from congenital oblique talus. Helpful clues can be from X-rays. Also, other conditions like tarsal coalition and pes planovalgus should be considered.
• Congenital oblique talus: For diagnosing this, we have to confirm that it’s not congenital vertical talus or pes planovalgus.
• Metatarsus adductus: This condition can make a child walk with their toes turned inward, can be confused with conditions that involve rotations in the leg bones.
• Skew foot: Lastly, skew foot can be mistaken for simple or complex metatarsus adductus, equinovarus, and flat foot.

Remember, each foot deformity is unique and requires the correct diagnosis for proper treatment.

What to expect with Pediatric Foot Alignment Deformities

The outcome of foot deformities greatly depends on what caused the deformity and its complexity. It also matters whether the deformity is the patient’s primary health issue or whether it comes along with other medical issues.

For clubfoot, a treatment method known as the Ponseti method has been successful about 90% of the time in avoiding a certain type of surgery called posteromedial release (PMR). Kids treated with this method are typically able to walk, run, and be active once the treatment finishes.

For a foot deformity known as planovalgus, the outcome can depend on various factors like age and other health risks. But usually, it gets better on its own over time, especially in kids.

For cavovarus foot deformities, the outcome is related to whatever condition caused the deformity.

For a deformity known as congenital vertical talus, the outcome depends on the child’s age when they were diagnosed and the severity of their condition.

With congenital oblique talus deformity, the situation can vary because it might be considered a different natural form of foot structure. Therefore, the outcome depends on how severe the deformity is.

In the case of metatarsus adductus, there is an excellent outcome with 90% of these types of deformities healing on their own without any intervention.

For skew foot, outcomes can vary. In severe cases, it might cause the person to have foot pain or to have problems with how their foot functions.

Possible Complications When Diagnosed with Pediatric Foot Alignment Deformities

There can be complications associated with foot deformities. These can come from the progression of the deformity without proper treatment, or can occur as a result of failed treatment.

For example, clubfoot can result in a relapsed deformity if treatment isn’t followed properly. The use of foot abduction orthosis (FAO) is critical to prevent this from happening. Repeating a method called the Ponseti method casting might be enough for children under two years old, whereas older children might require Achilles-lengthening procedures and tendon transfers. There may also be a deformity known as rocker bottom, especially if one deformity is corrected before another. After using the Ponseti method, any leftover dynamic supination can be managed with an anterior tibialis transfer with good results.

When treating clubfoot surgically, complications can include:

• Under-correction
• Dorsal bunion
• Residual cavus
• In-toeing gait
• Pes planus
• Other postoperative complications

Planovalgus can potentially lead to conditions like lingering pain or arthritis. There are also possible postoperative complications like infection, issues with surgical hardware, incorrect bone restructuring, or lack of bone healing.

Cavovarus, on the other hand, can result in a rigid deformity if there’s a delay in diagnosis. Complications might include ankle instability, stress fractures of the 4th and 5th metatarsal bones, issues with the peroneal tendon, and plantar fasciitis. Chronic ankle instability might even lead to arthritis.

Congenital vertical talus can cause a fixed deformity known as “rocker-bottom” if it’s not treated. Diagnosis after age two may require a complex surgery known as triple arthrodesis.

Congenital oblique talus usually doesn’t cause complications if it’s a physiological, anatomical variant. In more severe cases, or if it’s associated with neurological conditions, it might lead to a permanent foot deformity and difficulty walking.

With metatarsus adductus, nonsurgical treatment doesn’t usually cause complications. On the other hand, surgical intervention has a history of high complication rates. Potential complications can include:

• Stress risers
• Osseous bridging between the metatarsal bones
• Loss of purchase of the distal cortex
• Inability to hold correction
• Unequal bone removal when surgery is performed on all metatarsals

Lastly, Skew foot deformity, if untreated, may impair walking and foot development.

Preventing Pediatric Foot Alignment Deformities

It’s important that both children and their parents understand the causes of foot deformity in children. Parents should also keep in mind that how seriously the foot deformity affects the child depends on how severe and complex the deformities are. As a result, different treatment methods may be needed, varying from simply monitoring the situation, to using a cast, or even to performing surgery.

In many cases, these deformities are present at birth. However, they can also be caused by conditions affecting the nerves or glands in the body, or by genetic disorders.