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The aim of the study was to determine the relationship between flatfoot morphology and body mass and height in children aged 6-12 years. A total of 6471 Chinese children (mean age 9.0 ± 1.9 years, 41% female) were assessed for foot morphometry, body height, and body mass index. Foot morphology, including foot length, width, girth, arch height, hallux valgus angle, and rearfoot valgus angle, was measured using a 3D laser scanner. Flatfoot evaluations were conducted using the Sztriter-Godunov index (KY) from footprints. All measurements were analyzed by age and sex using the mean values of the left and right sides. Comparisons were performed between flatfoot groups, between body mass index (BMI) groups, and between body height groups. The study revealed a significant decrease in the incidence of bipedal flatfoot with age (p < 0.001), whereas the prevalence of obesity remained consistent (p > 0.05). Bipedal flatfoot was associated with distinct morphological changes, including lower arches, reduced instep height, diminished ankle heights and a greater rearfoot valgus angle (p < 0.05). When comparing the BMI groups, overweight children had larger and thicker feet (p < 0.05), but no differences were found in arch height and ankle height (p > 0.05). When comparing the body height groups, short-statured children had a shorter feet girth, shorter arches, and shorter ankle height (p < 0.05), but no differences were found in the rearfoot valgus angle (p > 0.05)., Conclusion: The main characteristics of flat feet include lower arches and instep heights and ankle heights but higher rearfoot valgus angles. In general, overweight children's feet do not have the common features of flat feet. In contrast, short children had similar features of flatfoot except for rearfoot valgus. Assessment of posture, such as rearfoot valgus, can be critical in identifying children with flat feet., What Is Known: • The morphology of children's feet is associated with body growth, but the relationship between flatfeet and body mass and height remains controversial., What Is New: • Three-dimensional foot measurement shows that body mass is generally not associated with flatfeet, while short children have lower arches but no rearfoot valgus., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Aim: Foot involvement is present in approximately 60%-90% of children with Juvenile idiopathic arthritis (JIA). It is a major cause of disability, which can lead to deterioration in daily activities and quality of life. However, it is often overlooked and can compromise patient management., Purpose: Our objective was to describe the ankle and foot involvement in JIA and to appraise the functional impact of this damage on the child's performance and quality of life by using validated scores., Methods: The cross-sectional study included patients with JIA. Functional impairment was assessed through the Juvenile Arthritis Functionality Scale (JAFS) and the Oxford Ankle and Foot Questionnaire for children., Results: Twenty-three patients aged 12.75 ± 3.9 and with 41 months of disease duration. After completing the Oxford score, the physical domain appeared to be the most altered. A long delay in diagnosis was associated with an alteration in the emotional domain of the Oxford score. Higher disease activity was significantly associated with impairment in both the physical activity and the footwear domains of the Oxford score. As regards clinical examination data, the presence of foot pain as well as the presence of tendinopathy were associated with an alteration of all Oxford score domains. The presence of flat feet significantly affected all domains of the Oxford score. The JAFS was reported to affect the child's performance ability and was associated with impairment in physical activity, school and play, and emotional domains., Conclusion: Ankle and foot involvement was common in our study. Functional ability was most impaired in the lower limbs. High disease activity, foot and ankle pain, tenosynovitis, and flat feet were associated with poorer quality of life and higher functional impact., (© 2023 John Wiley & Sons Ltd.)

The foot resembles a tripod. The 3 legs consist of (1) the tip of the heel, (2) the first metatarsal, and (3) the fifth metatarsal. This concept is useful to explain cavus or flat feet. When the tips of the tripod move closer, the arch becomes higher. The leg of the tripod that moves the most will determine the type of cavus feet, which can be hindfoot cavus, forefoot cavus, or first metatarsal cavus. Cavovarus foot denotes the presence of a three-dimensional deformity of the foot, but it is much more a descriptive feature than a diagnosis., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: The abnormal plantar pressure of flatfoot patients is a common condition. The main objective of the present study was to investigate the effect of custom-molded insole on the plantar pain of flatfoot METHODS: 105 patients (representing 174 feet) participated in evaluating a custom-made orthotic insole from June 2018 to March 2019. The height of the navicular tubercle (HNT) and the deflection angle of calcaneus (DAC) in flatfoot patients after using orthotic insoles for 6 months were recorded by X-ray imaging and scanning measurements. Plantar pressure on metatarsals 1-5 was measured by using an RSscan system RESULTS: Without the use of an orthotic insole, mean HNT was 0.99±0.34 cm and mean DAC was 20.0 ± 3.78 ° during the bearing weight. After using the insole, mean HNT and DAC values reduced to 0.87±0.30 cm and 14.3 ± 3.45 °, respectively (P < 0.05). Hindfoot plantar pressure did not change significantly (P > 0.05). Furthermore, pressure at metatarsals 1-3 decreased by 48.5 %, 45.6 %, and 14.3 %, respectively; that at metatarsals 4-5 increased by 33.3 % and 137.5 %, separately, when using the custom-made insole CONCLUSIONS: Visual analog scale score for plantar pain was significantly reduced. These findings indicate that metatarsal pain of flatfoot patients might be the cause of load imbalance in plantar foot., Competing Interests: Declaration of Competing Interest There are no conflicts of interest for this study., (Copyright © 2023 IPEM. Published by Elsevier Ltd. All rights reserved.)

Background: Few studies have reported the clinical outcomes of fusion surgeries for type II accessory naviculars. Whether the combination of accessory naviculars and asymptomatic flatfoot will result in worse outcomes in accessory navicular surgeries remains to be elucidated. Our study aims to report the clinical outcomes of fusion for type II accessory naviculars and make a subgroup comparison among accessory navicular patients with or without asymptomatic flatfeet., Methods: From May 2017 to June 2021, all painful type II accessory naviculars with or without asymptomatic flatfeet in our inpatient center were reviewed, and those who only underwent fusion surgeries were included in the retrospective study. Visual analog scale (VAS) scores, American Orthopaedic Foot & Ankle Society (AOFAS) midfoot scores, Tegner activity level scores, complications, patient-reported satisfaction, and imaging results (Meary angle in the weightbearing lateral view, talo-first metatarsal angle and talonavicular coverage angle in the weightbearing anteroposterior view) were used to describe outcomes., Results: Thirty-two eligible patients responded to the latest follow-up request and were included in this study. The mean follow-up duration was 37.1 ± 16.0 months. The average VAS pain score improved from 4.7 ± 1.8 preoperatively to 0.9 ± 1.2 at the latest follow-up ( P <.001). The average AOFAS midfoot score improved from 67.1 ± 8.5 preoperatively to 90.2 ± 10.7 at the latest follow-up ( P <.001). The preoperative and postoperative Tegner activity level scores were similar (3.3 ± 1.5 vs 3.5 ± 1.6, P =.136). The overall complication rate was 37.5%. The most common complication was nonunion (31.3%). The overall satisfaction rate was 90.6%. Similar outcomes were observed between the flatfoot and the nonflatfoot subgroups., Conclusion: Fusion for painful type II accessory naviculars resulted in good symptom relief, function improvement, and patient satisfaction at midterm follow-up, but the nonunion rate was relatively high. Fusion for painful type II accessory naviculars with or without asymptomatic mild to moderate flatfoot brought about similar clinical outcomes., Level of Evidence: Level III, retrospective comparative study.

The complex adult acquired flatfoot deformity involves progressive collapse of the foot with attenuation of medial soft tissues such as the posterior tibialis tendon and spring ligament complex. Multiple deformities at different levels can coexist in the collapsed foot, including hindfoot valgus, midfoot abduction, forefoot varus, and valgus ankle instability. Definitions of flatfoot have evolved to encapsulate the peritalar basis of the deformity, with instability around the talus as the fulcrum. The goals of treatment are to minimize pain, dysfunction, and progressive deformity. Some treatment options directly address the pathologic areas, such as tendon transfer for posterior tibialis tendon dysfunction and spring ligament reconstruction. Others such as calcaneal osteotomies secondarily counteract the primary ligamentous dysfunction and realign the foot to neutralize deforming forces. Selective fusions of the hindfoot and medial column are also viable options to correct the deformity at the joint level when appropriate. The treatment selected depends on flexibility and locations of the deformity, and ultimately patient-specific factors.

Forefoot varus develops as a result of longstanding adult-acquired flatfoot deformity (AAFD). This occurs with varying degrees of deformity and flexibility. Residual forefoot varus following hindfoot realignment in AAFD can lead to lateral column loading and a persistent pronatory moment in efforts to reestablish contact between the forefoot and the ground. The Cotton osteotomy may serve as a reasonable adjunct procedure to help avoid complications and poor outcomes associated with residual forefoot varus in patients undergoing hindfoot arthrodesis for stage III AAFD. The aim of this study was to compare the radiographic outcomes in patients undergoing isolated hindfoot arthrodesis to patients undergoing hindfoot arthrodesis with adjunctive cotton osteotomy. We retrospectively reviewed 47 patients matched based upon age, sex, and comorbidities who underwent hindfoot reconstruction for the treatment of stage III AAFD between 2015 and 2019. A retrospective radiographic review was performed on standard weightbearing radiographs including anterior-posterior and lateral views preoperatively, postoperatively at the initiation of full weightbearing, and at final follow-up. Statistical analysis utilizing paired t test to calculate p values where <.05 was statistically significant. At final follow-up, radiographic measurements showed statistically significant differences in CAA, calcaneal inclination, talo-calcaneal, and talar tilt (p value <.05). The Cotton osteotomy group showed a quicker return to presurgical activity level and a decreased incident of tibiotalar valgus. Our study suggests that the Cotton osteotomy can address residual forefoot varus and potentially prevent further progression of ankle valgus in AAFD when used in combination with hindfoot arthrodesis., (Copyright © 2021 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Mitral Valve Prolapse (MVP) is a common valvular abnormality accounting for 2% of the population. There is a reported association between pes planus (PP) and MVP in some syndromes such as Marfan. However, this association has not been tested in non-syndromic cases. The primary outcome of this study is to measure the prevalence of MVP in a population of patients with PP. The secondary outcome parameter is to determine if the Meary angle (MA), a measure of the severity of flat foot, can be effectively used in the prediction of the presence of MVP. Forty-one patients with PP were screened using a lateral x-ray foot to determine MA while echocardiography was utilized to identify the presence and grade of MVP., Results: 88% of screened patients were diagnosed with MVP. MA was correlated with the grade of MVP and showed high diagnostic accuracy (sensitivity 100% and specificity 90%) in predicting MVP risk when higher than 5. Children with PP are at a higher risk for MVP than the general population. Accordingly, the utilization of MA in such a specific population for the determination of patients at a higher need for echocardiography seems to be a worthwhile strategy in diagnosing MVP., (© 2022. The Author(s).)

This article introduces novel types of ankle arthritis related to a flatfoot deformity. There has been a long-held belief that severe unmanaged flatfoot deformity leads to valgus ankle arthritis, due to deltoid ligament insufficiency. However, flatfoot deformity can also give rise to varus ankle arthritis as the talus and calcaneus subluxate into opposite directions. Plantarflexion and posterior translation of the talus in the sagittal plane contributes to the eccentric narrowing of the posterior aspect of the tibiotalar joint, which the authors termed posterior ankle arthritis. Subtalar arthrodesis was performed to address the opposing dynamics of the talus and calcaneus, and was combined with a medial longitudinal arch reconstruction in most cases of posterior ankle arthritis and in selected cases of varus ankle arthritis, and satisfactory clinical and radiological results were achieved., Competing Interests: Disclosure J. Kim and W-C. Lee have nothing to disclose pertaining to this topic., (Copyright © 2021 Elsevier Inc. All rights reserved.)

49,XXXXY is the rarest X and Y chromosomal variation, with an incidence of 1 in 80,000-100,000 live male births and has been associated with numerous musculoskeletal abnormalities. Data was collected from an international cohort of boys with 49,XXXXY over 10 years. Children were evaluated by a multidisciplinary team consisting of a pediatric orthopedist, a neurogeneticist, a neurodevelopmentalist, and two physical therapists. Increased rates of torticollis (32.4%), hamstring tightness (42%), radioulnar synostosis (67.6%), pes planus (65.2%), and other foot abnormalities (86.9%) were observed. Several anomalies increased with age, specifically hamstring tightness, kyphosis, and scoliosis. The elucidation of the orthopedic profile of this population is necessary in order to provide healthcare providers with current medical information. This research further supports the necessity for the comprehensive multidisciplinary treatment of boys with 49,XXXXY., (© 2020 Wiley Periodicals, Inc.)

BACKGROUND. Tearing of the superior peroneal retinaculum is a known cause of peroneal tendon subluxation-dislocation. However, with the exception of cortical avulsions at the fibular attachment, superior peroneal retinaculum injury and subsequent peroneal tendon subluxation-dislocation are typically radiographically occult. OBJECTIVE. The purpose of this study was to evaluate the previously undescribed association between radiographic fibular tip periostitis and MRI evidence of peroneal tendon subluxation-dislocation in patients with hindfoot valgus. METHODS. Thirty-five patients with radiographic fibular tip periostitis and 35 ageand sex-matched individuals without periostitis were selected from among 220 consecutively registered patients with hindfoot valgus who had undergone both ankle radiography and MRI. Studies were retrospectively assessed by two musculoskeletal radiologists in consensus and by two additional blinded radiologists independently for the presence of peroneal tendon subluxation-dislocation, presence of subfibular impingement, and hindfoot valgus angle measurements. Interobserver agreement and accuracy, sensitivity, and specificity in the detection of fibular periostitis, peroneal tendon subluxation-dislocation, and subfibular impingement were calculated, and Fischer exact, Mann-Whitney, kappa coefficient, and intraclass correlation tests were performed. RESULTS. Both the consensus and the two independent interpretations showed that the frequency of peroneal tendon subluxation-dislocation was significantly greater in the group with periostitis (62.9%, 65.7%, and 85.7%) than in the group without periostitis (5.7%, 0%, and 14.3%) ( p < .001). The finding of periostitis was specific and highly sensitive for predicting peroneal tendon subluxation-dislocation. The frequency of subfibular impingement was also statistically higher in the group with periostitis than in the group without it ( p < .001). The hindfoot valgus angle was statistically larger in the group with periostitis than in the control group ( p = .01-.002) and among patients with versus those without peroneal tendon subluxation-dislocation ( p = .002 to p < .001). The blinded readers had substantial or almost perfect agreement on all imaging interpretations (concordance rate, 82.9-95.7%; κ = 0.66-0.91). CONCLUSION. The radiographic finding of fibular tip periostitis in patients with hindfoot valgus can be a predictor of peroneal tendon subluxation-dislocation and may also suggest advanced hindfoot valgus and subfibular impingement. These radiographic associations should be recognized by the radiologist, and MRI may be recommended as clinically indicated. CLINICAL IMPACT. Chronic undiagnosed peroneal tendon subluxation-dislocation can be a persistent cause of lateral ankle pain, leading to further degeneration and the possibility of complete peroneal tendon tears. Distal fibular periostitis in patients with hindfoot valgus can be a reliable radiographic indicator of this entity and may suggest the presence of subfibular impingement.

Context: Arch height is one important aspect of foot posture. An estimated 20% of the population has pes planus and 20% has pes cavus. These abnormal foot postures can alter lower extremity kinematics and plantar loading and contribute to injury risk. Ankle bracing is commonly used in sport to prevent these injuries, but no researchers have examined the effects of ankle bracing on plantar loading., Objective: To evaluate the effects of ankle braces on plantar loading during athletic tasks., Design: Cross-sectional study., Setting: Laboratory., Patients or Other Participants: A total of 36 participants (11 men, 25 women; age = 23.1 ± 2.5 years, height = 1.72 ± 0.09 m, mass = 66.3 ± 14.7 kg) were recruited for this study., Intervention(s): Participants completed walking, running, and cutting tasks in 3 bracing conditions: no brace, lace-up ankle-support brace, and semirigid brace., Main Outcome Measure(s): We analyzed the plantar-loading variables of contact area, maximum force, and force-time integral for 2 midfoot and 3 forefoot regions and assessed the displacement of the center of pressure. A 3 × 3 mixed-model repeated-measures analysis of variance was used to determine the effects of brace and foot type (α = .05)., Results: Foot type affected force measures in the middle (P range = .003-.047) and the medial side of the foot (P range = .004-.04) in all tasks. Brace type affected contact area in the medial midfoot during walking (P = .005) and cutting (P = .01) tasks, maximum force in the medial and lateral midfoot during all tasks (P < .001), and force-time integral in the medial midfoot during all tasks (P < .001). Portions of the center-of-pressure displacement were affected by brace wear in both the medial-lateral and anterior-posterior directions (P range = .001-.049)., Conclusions: Ankle braces can be worn to redistribute plantar loading. Additional research should be done to evaluate their effectiveness in injury prevention., (© by the National Athletic Trainers' Association, Inc.)

Introduction: Flatfoot deformity is commonly characterized by a subtalar valgus, a low medial longitudinal arch, and abduction of the forefoot. Although flatfoot deformity has been associated with lower first (KAM1) and second (KAM2) peak knee adduction moments during walking, the biomechanical connection remains unknown., Research Question: We hypothesized that hindfoot eversion, lateral calcaneal shift correlate with KAM1 and forefoot abduction and arch height with KAM2, due to the lateralization of the ground reaction force vector resulting from shifted heel and forefoot in flatfoot deformity., Methods: Gait data from 103 children with flatfoot deformity who underwent three-dimensional gait analysis with the Oxford Foot Model were retrospectively included. Children with knee varus/valgus, in- and out-toeing were excluded. Fifteen healthy children with a rectus foot type were also collected from the database. Lateral calcaneal shift was defined as the distance between the projection of the ankle joint center onto the calcaneal axis and the midpoint of the calcaneal axis formed by the medial and lateral calcaneal markers. A subgroup of children with idiopathic flatfoot deformity that had received corrective surgery was also identified. Statistical analysis included Pearson's correlations and independent and paired t-tests (α < .05)., Results: When compared to a norm cohort, flatfooted children had significant lower KAM1 and KAM2 (t-test, P < .001). Lateral calcaneal shift correlated with KAM1 and KAM2 (r = 0.42, p < .001 and r = 0.32, P < .001, respectively). Arch height correlated with KAM2 (r = 0.23, p = 0.017). KAM1 and KAM2 normalized after surgery and the change in KAM1 correlated with the change in lateral calcaneal shift for children who underwent corrective surgery., Significance: Lateral calcaneal shift explains the reduction of KAM1 by lateralization of the point of force application in flatfooted children. It is recommended to consider the lateral calcaneal shift when investigating KAM in gait analysis research., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: Flexible flatfoot is a common deformity in adults that has been thought to be a causative factor of a lot of lower limb injuries and back pain. Core muscles act as stabilizers for the trunk and weak core places a person at greater risk of low back pain and lower limb injuries. We aimed to compare the core muscles' endurance between individuals with and without flatfeet., Methods: Thirty subjects with bilateral flexible flatfeet (study group) were compared with thirty healthy subjects (control group). Navicular drop test was used to evaluate the medial longitudinal arch. Modified back extensors, modified flexion and lateral muscles' endurance tests were used to evaluate the endurance of the core muscles., Results: The lateral muscles' endurance time in the flatfeet group was found to be significantly lower than that of the healthy group on both sides (p=0.0001). However, no significant difference was found in the trunk flexors' (p=0.15) and trunk extensors' (p=0.27) endurance time between both groups., Conclusions: Impairment of the lateral core muscles' endurance was observed in subjects with bilateral flexible flatfeet which may predispose to low back pain and other lower limb injuries in those subjects., Competing Interests: The authors have no conflict of interest.

Background: The acquired adult flatfoot deformity (AFFD) is a potentially debilitating foot condition with a prevalence thought to be between 3 %-10 %. To the authors' best knowledge, no association has been described between severity of AFFD and degree of pre-existing ankle or foot arthritis. The degree and pattern of preexisting ipsilateral arthritis of the foot and ankle was investigated in those with symptomatic AFFD presenting to hospital., Methods: Retrospective observational study between May 2015 and May 2018, of patients who presented to our tertiary clinic with symptomatic AFFD. Radiographs of one hundred and forty-eight (n=148) patients were reviewed, excluding those with charcot arthropathy, previous trauma or coalition. The primary outcome measure was severity of OA in the ankle, subtalar, talonavicular and calcaneocuboid joints. Secondary outcome was severity of radiographic planovalgus deformity. The independant variables used were age and severity of planovalgus deformity as measured by the Meary angle, calcaneal pitch and medial cuneiform-fifth metatarsal height. A linear regression model was carried out on the outcomes., Results: Median age was 60.0 years (IQR 22). There were 56 males to 92 females, with 75 left sided deformities observed and 73 right sided. With increasing severity of planovalgus measurements, there was no significant association observed in severity of arthritis in the ankle joint (p = 0.766), subtalar joint (p = 0.090), talonavicular joint (p = 0.256) and calcaneocuboid joint (p = 0.091). With increasing age, there was significance observed in degree of ankle arthritis, subtalar, talonavicular and calcaneocuboid joints (p = 0.001). There was no significant correlation observed with age for the angular break of Meary's line (p = 0.73), calcaneal pitch (0.262) and medial cuneiform-fifth metatarsal height (p = 0.937)., Conclusion: This observational study shows no significant association between severity of radiographic planovalgus deformity and pre-existing arthritis of the ankle, hindfoot and midtarsal joints., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Hallux valgus (HV) and Pes Planus (PP) are two common conditions characterized by aesthetic dissatisfaction with or without pain. The aim of the study was to assess clinical and functional outcomes at two years follow-up of percutaneous surgery in patients with HV and concomitant not-symptomatic PP. From January 2014 to May 2015 a total of 12 females and 2 males (14 feet) were enrolled in the study (mean age 41.9±13.28). The inclusion criteria were patients with HV surgically treated with the percutaneous approach, mild or moderate not symptomatic PP at 24 months follow-up. Percutaneous distal metatarsal osteotomy and exostectomy is performed for all patients and followed by a weekly bandage. American Orthopaedic Foot and Ankle Society (AOFAS) score for HV (AOFAS-HV), patient satisfaction, and preoperative and postoperative X-ray at 6 weeks follow-up were evaluated. Numerical data are reported as the mean± SD and 95% confidence intervals. The pre-operative hallux valgus angle (HVA) was 30.14°±11.26°, the post-operative HVA was 18.36°±10.13 with a mean correction of 11.79°±2.67° with p<0.0001. Mean AOFAS-HV increased from 42.07±10.82 pre-operatively to 83±8.96 post-operatively with p<0.0001. One out of 14 patients had recurrence of HV without needing revision surgery at the last follow-up. All patients were satisfied with the clinical outcomes. Our results suggested that percutaneous osteotomy with the mini-burr is an effective treatment for patients with HV despite PP presence, even if the mean functional score was slightly worse when compared with the literature.

Hallux valgus is one of the most common and painful deformities, occurring due to adductor/abductor imbalance of the big toe. Many structural foot disorders have been suggested as the cause of hallux valgus deformity. In this study, we aimed to show the relationship between hallux valgus and pes planus in adult males. A total of 213 patients were included in this study between May 2013 and May 2014. 54 patients with hallux valgus angle (HVA) >20° and intermetatarsal angle (IMA) >9° were evaluated in the case group and 159 patients randomly selected from those admitted for a recent foot ankle trauma with the HVA <15° and IMA <9° were the control group. All patients' HVA, IMA, and talonavicular coverage angle on anteroposterior (AP) foot radiographs and talar-first metatarsal angle (Meary's angle), calcaneal pitch angle, and lateral talocalcaneal angle on lateral foot radiographs were measured. There was no significant difference in talonavicular and Meary's angles between the groups. Calcaneal pitch angle was significantly lower in the case group, whereas talonavicular angle was higher in the control group. Calcaneal pitch angle and lateral talocalcaneal angle showed significant negative correlation with HVA and IMA. There are few reports in the literature about the relationship between pes planus and hallux valgus. Our results strongly showed a high correlation between pes planus and hallux valgus. Further larger patient cohort studies are needed to support our results., (Copyright © 2019 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The management of painful rigid flatfoot (RFF) with talocalcaneal coalition (TCC) is controversial. We aimed to compare operative and nonoperative treatment in children with RFF and TCC., Methods: We retrospectively reviewed medical records and radiographs of children with RFF and TTC treated between 2005 and 2015. The nonoperative treatment consisted of manipulation under anesthesia, cast immobilization and shoe insert after cast removal. The operative treatment consisted of combined TCC resection, graft interposition and subtalar arthroereisis., Results: Thirty-four children (47 ft) in the nonoperative group and twenty-one children (34 ft) in the operative group were included. No differences were found between groups, concerning baseline characteristics. The mean age at treatment was 11.8 years (9-17): 11.6 (9-17) for the nonoperative group, 12.2 (10-15) for the operative group. The mean follow-up averaged 6.6 (3-12) years and was significantly longer in the nonoperative group (7.8 versus 4.7 years; p < 0.0005), since the operative procedure was increasingly practiced in the latest years. There were no complications in either groups, but 6 patients (7 ft) in the nonoperative group were unsatisfied and required surgery. At the latest follow-up, the AOFAS-AHS improved in both groups, although the operative group showed significantly better improvement. The operative group reported also significantly better FADI score, after adjustment for follow-up and baseline variables., Conclusion: The operative treatment showed better results compared to the nonoperative treatment. Symptomatic RFF with TCC in children can be effectively treated in one step with resection, graft interposition and subtalar arthroereisis. Further prospective randomized studies are needed to confirm our findings and to identify the best operative strategy in this condition.

Competing Interests: Competing interests The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: none. Further details of The BMJ policy on financial interests are here: https://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests

Objective: The aim of this study was to determine the potential association of foot pain and plasmatic adipocytes as physiological biomarkers of childhood obesity with the incidence of flatfoot in a cohort of Egyptian school children aged 6 -12 years., Methods: A total of 550 Egyptian schoolchildren (220 boys and 330 girls) aged 6-12 years were randomly invited to participate in this descriptive survey analysis. For all children, we assessed the diagnosis and severity of flatfoot as well as plasma adipocytes, as well as adiponectin, leptin, resistin, IL-6, and TNF-α, using the Dennis method and immunoassay techniques respectively. Foot pain was assessed by using a standard VAS of 100 mm and Faces Pain Scale, respectively., Results: Flat foot was predicted in 30.4% of school-age children, most of them showed a higher frequency of overweight (33.3%) and obesity (62.5%). Boys showed higher ranges of flat foot than girls. Foot pain significantly correlated with flat foot and obesity among the studied populations. In overweight-obese children, plasmatic adipocyte variables, as well as adiponectin, leptin, resistin, IL-6, TNF-α showed significant correlations with foot stance, especially in boys. Also, the studied adipocyte variables along with BMI, age, gender explained about~65% of the variance of flatfoot with pain among our school-age students., Conclusion: Foot pain showed an association with flat foot and childhood obesity in 30.4% of school-age students (6-12 years). Foot pain was shown to correlate positively with the incidence of flat foot and changes in adiposity markers, as well as adiponectin, leptin, resistin, Il-6, TNF-α.

Multiple accessory navicular bones is an extremely rare condition. To the best of our knowledge, only 8 cases in 2 imaging studies have been published. We report a case of a patient with flat foot with 2 accessory navicular bones. This patient needed to be treated surgically, and the surgery was successful, with short-term follow-up. We believe this is the first case of multiple accessory navicular bones to be treated surgically in English literature. The incidence of multiple accessory navicular bones might be higher. There is a risk to remaining ossicles without resection or fixation during surgery; therefore, we strongly recommend using not only radiographs, but also 3-dimensional computed tomography scans or magnetic resonance imaging scans to confirm the type of accessory navicular bone, at least before surgery, for both painful accessory navicular bone and flat foot with accessory navicular bone., (Copyright © 2018 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Chronic deformity of the foot can lead to ulceration, infection, and amputation. Midfoot wedge osteotomy for deformity correction has been described in the literature; however, most reports are case review or small series. Wedge osteotomy can be performed from a medial or plantar approach, but there are limited data on outcomes regarding these relatively uncommon procedures. This study aims to review a population of patients with a rocker bottom foot deformity that underwent a midfoot wedge resection performed from the plantar surface for deformity correction, wound healing, and limb salvage. A review of medical records from a single foot and ankle surgeon was undertaken. Patients who had a midfoot wedge performed from the plantar surface to address rocker bottom deformity resulting from Charcot neuroarthropathy or severe flatfoot were included. Thirty patients met inclusion criteria. The outcome measures evaluated were minor and major complications, wound healing, and functional limb status. Statistical analysis was performed to evaluate factors that influenced outcomes. At time of final follow up, 17 of 20 (85%) preoperative wounds had healed. Mean preoperative talo-first metatarsal angle was -25° and improved to -5° postoperatively. An 87% limb salvage rate (26/30) was demonstrated. Body mass index was the only statistically significant factor that influenced functional limb status. Maintaining a functional limb can have profound effects on a patient's quality of life. Generally, patients with this severe rocker bottom foot deformity have multiple comorbidities and are at an increased risk of major amputation and early death. The current study has shown that patients with a rocker bottom foot deformity can benefit from midfoot wedge resection from a plantar approach to achieve a plantigrade foot., (Copyright © 2019 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Foot orthoses are widely used in conservative treatment of painful flexible flatfoot (PFFF) however research is limited to choose the best option in orthotic treatment., Aim: We aimed to compare the effects of computer-aided design/computer-aided manufacturing (CAD-CAM) and conventional insole types in comparison with sham insole, on pain and health related quality of life in patients with PFFF., Design: Randomized controlled trial., Setting: Outpatient rehabilitation clinic., Population: Sixty-seven people with PFFF, aged between 18 and 45 years, were assigned to CAD-CAM (N.=22), conventional (N.=22) or sham (N.=23) groups., Methods: In addition to insoles, a home-based exercise program was followed by all participants for eight weeks. Foot pain intensity and quality of life were assessed at the initial evaluation and at the end of two-month follow-up., Results: Pain intensity (Mean±SD, mm on VAS) was significantly lower in CAD-CAM (27.84±18.41) and conventional (27.05±16.82) insole groups than sham group (46.39±20.18) after two months (P<0.05), but there was no difference between conventional and CAD-CAM (P>0.05). All groups had significantly higher physical health scores at the second assessment (P<0.05), but there was no intergroup difference (P>0.05)., Conclusions: CAD-CAM and conventionally designed insoles are both more effective than having sham insole in alleviating pain in PFFF., Clinical Rehabilitation Impact: CAD-CAM and conventionally designed semicustom insoles in conjunction with a home-based exercise program are both effective in controlling pain compared with sham insole and exercise in PFFF. Clinicians can prescribe both types of semicustom insoles as a part of conservative treatment instead of each other.

Background:: Lateral hindfoot pain in patients with flatfoot deformity is frequently attributed to subfibular impingement. It remains unclear whether this is primarily due to bony or soft-tissue impingement. No studies have used weight-bearing CT scans to evaluate subfibular impingement., Methods:: Patients with posterior tibial tendonitis were retrospectively searched and reviewed. Subjects had documented flatfoot deformity, posterior tibial tenderness, weight-bearing plain radiographs, and a weight-bearing CT scan. CT scans were evaluated for calcaneofibular impingement on the coronal view and talocalcaneal impingement on the sagittal view. The distance between these structures was measured, along with the sinus tarsi volume. In the second part of this study, 6 normal volunteers underwent weight-bearing CT scans on a platform that held both feet in 20 degrees of varus, followed by 20 degrees of valgus. The same measurements were performed., Results:: Thirty-five percent of flatfoot patients with posterior tibial tendonitis had bony impingement between the fibula and calcaneus on the coronal view. Thirty-eight percent had bony impingement between the talus and calcaneus on the sagittal view. Subjects with bony impingement based on CT scan had significantly higher talonavicular abduction angles on plain radiographs than those without impingement. Sinus tarsi volume decreased by more than half when the subtalar joint moved from varus to valgus in normal controls., Conclusion:: Bony subfibular impingement in patients with flatfeet was less common than previously reported. Accurate diagnosis of bony impingement may be useful for surgical decision-making., Level of Evidence:: Level III, retrospective comparative study.

Background: Pedal biphalangism, which was also defined as symphalangism, is seen at a frequency that cannot be ignored; however, no study can be found in the literature evaluating biphalangism in normal population in comparison to those who have foot disorders. The aim of this study was to evaluate the incidence of the pedal fifth toe symphalangism in normal population and in patients with foot deformity including hallux valgus, pes planus, pes cavus, and pes equinovarus. We hypothesized that pedal fifth toe symphalangism may be a predisposing factor or an accompanying structural variation for foot deformity., Materials: Patients admitted to the emergency department of our center in October and November 2016 were defined as the control group, and patients with the diagnosis of hallux valgus, pes planus, pes cavus, and pes equinovarus treated between 2011 and 2016 in our department were defined as the foot deformity group. Individuals who had anteroposterior, oblique, and lateral radiographs of foot were included in the study., Results: One thousand and four patients participated in the cross-sectional observational study. Biphalangeal fifth toe was found in 328 of 1004 (32.7%) patients. In foot deformity group ( n = 672), 222 patients (33%) had biphalangeal fifth toe. In the control group, 106 (31.9%) of the 332 patients had biphalangeal fifth toe. There was no statistically significant difference in the incidence of biphalangeal fifth toe between the two groups ( p = 0.72)., Conclusions: According to the results of this study, biphalangeal fifth toe is a common pedal anatomical variant seen approximately in one-third of the population who have either foot deformity or not. This information may be valuable for podiatrist undertaking the conservative or surgical treatment of fifth toe-related disorders.

Background: While posterior tibial tendon dysfunction (PTTD) commonly presents with flat feet and has been thought to be associated with first ray mobility, many flat-footed individuals are asymptomatic and do not experience any symptoms of PTTD. Thus, there is a need to control for foot type when studying factors related to PTTD. This study aimed to clarify if first ray mobility differed between flat-footed individuals with and without symptoms of PTTD. It was hypothesized that PTTD patients would display higher mobility of the first ray than asymptomatic flat-footed controls., Methods: Given that PTTD patients were often flat-footed, asymptomatic flat-footed individuals were chosen as controls to remove flatfoot as a potential confounding factor. We recruited 32 flat-footed subjects, of which 16 exhibiting PTTD symptoms and 16 asymptomatic controls matched for age, sex and body mass index. First ray mobility was assessed using subjective classification ("stiff", "normal" or "hypermobile") and maximum dorsal displacement using a ruler indicator. Mann-Whitney U was used to test for between-groups differences., Results: Subjective classification was similar between PTTD and control groups (both groups: 38% "normal" joint mobility). No significant differences were found between PTTD patients and asymptomatic controls in first ray displacement [median (IQR), PTTD: 6.00 (1.75) mm; control: 6.00 (1.00) mm; P=.31]., Conclusions: First ray mobility was not associated with PTTD in flat-footed persons. When evaluating symptoms of PTTD, clinicians should pay attention to factors other than first ray mobility., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Plano-valgus is a common alteration of the paediatric foot, characterized by valgus hindfoot, foot pronation and drop of the medial longitudinal arch. Despite their importance in the diagnosis and classification of plano-valgus foot condition, little information is available on functional alterations of the major joints spanning the medial longitudinal arch - i.e. midtarsal and tarso-metatarsal. Aim of the study was to provide objective description of the alterations in plano-valgus midfoot joints with respect to those in an age-matched normally-developed feet population., Methods: Twenty adolescents (13.3 ± 0.8 years) with bilateral plano-valgus feet underwent clinical examination and were gait-analysed via a validated 4-segment foot model. This allowed to measure static foot posture, kinematics of the main foot joints, and medial longitudinal arch deformation during walking at comfortable speed. Range of motion and temporal profiles of joint rotations were compared to those from a control population of age-matched adolescents with normally-developed feet., Results: The plano-valgus midtarsal joint was more dorsiflexed, everted and abducted than that in the control group, and showed reduced sagittal-plane RoM (plano-valgus = 15.9 degrees; control = 22.2 degrees; P  <  0.01). The tarso-metarsal joint was more plantarflexed and adducted, and showed larger frontal-plane RoM. The MLA showed larger RoM and was lower throughout the stance phase of the gait cycle., Conclusion: Significant postural and kinematic alterations are present at the midtarsal and tarso-metarsal joints of adolescents with plano-valgus feet. Objective identification and quantification of plano-valgus foot alterations, via non-invasive gait-analysis, is relevant to improving the diagnosis of this condition and to evaluating the effect of conservative treatments and of surgical corrections by different techniques., Competing Interests: Acknowledgement of the Hospital’s IRB was granted (protocol n° 7/17) and parents’ informed consent was obtained for all children recruited in the study.Parents’ consent to publish was granted.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The insufficiency of the posterior tibial tendon is the most common acquired cause of pain related to valgus flatfoot deformity in adults. The acquired flatfoot adult is a very painful symptomatic deformity resulting from a gradual stretching (attenuation) of the posterior tibial tendon and ligaments that support the arch of the foot. The progressive pain acquired flatfoot adult affects four times more women than men. Some factors that contribute to increased risk of acquired flatfoot in adults, are diabetes, hypertension and obesity. It is thought that the combination of the following events is the cause of acquired flatfoot adult. Johnson Strom classification modified by Mayerson evaluates in 4 stages. This study was divided into 3 stages: Stage 1: Dissection and three-dimensional analysis of the tendon, Step 2: Application of tools bioengineering to determine the causes of rupture of the tibial tendon: Stage 3: Evaluation of 24 patients with flatfoot disease valgus for describe the deformity.

Background: The prevalence of flexible flat feet in children was reported to be up to 20% in previous studies. However, the role of foot type in the development of musculoskeletal injuries is less clear, particularly in children. The purpose of this study was to investigate the differences in the joint moment asymmetry in children with flexible flat feet and healthy matched control subjects., Methods: Fourteen male children with flexible flat feet and 15 healthy control subjects served as the sample of the study. Three dimensional kinematics and kinetic data were collected using a Vicon camera system and two Kistler force platforms during walking. Then between-limb asymmetry was examined for each joint moment., Results: Normal individuals experienced higher asymmetry in the ankle eversion and the external rotation moments than the flat feet group. Asymmetry indices in the knee abduction, adduction, and the internal rotation moments in the flat feet group were higher than that in the normal group by 15%, 24% and 13%, respectively. Furthermore, in comparison of the two groups, individuals with flat feet had higher asymmetry in the hip flexion moment as well as the hip abduction moment., Conclusions: In order to provide appropriate protocols or footwear design for male children with flat feet, clinicians need to understand that flat feet children do not have higher levels of joint moment asymmetry as compared to normal children in all joints and all planes; consequently, they must differentiate their treatments for each specific joint. However, further larger study is warranted., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

This cross-sectional study examined the relationship of flat feet with knee pain, disability, and physical performance in patients with knee osteoarthritis (OA). Orthopedic clinic participants (n = 95; age 61-91 years; 68.4% women) with Kellgren-Lawrence (K/L) grade ≥1 in the medial compartment underwent evaluation of navicular height and foot length for flat feet. Knee pain intensity, disability, and physical performance were evaluated using the Japanese Knee Osteoarthritis Measure, 10-m walk, timed up and go, and five-repetition chair stand tests. Of the 95 enrolled patients, 24 (25.3%) had bilateral flat feet, and significantly higher knee pain compared to patients with no flat feet (11.3 ± 8.23 points vs. 6.58 ± 6.37 points; p = 0.043). A ordinal logistic regression analysis showed that bilateral flat feet were significantly associated with increased knee pain (proportional odds ratio: 5.48, 95% confidence interval: 1.96, 15.3; p = 0.001) compared with no flat feet, adjusted for age, sex, body mass index, and tibiofemoral joint K/L grade, which is consistent across various different cutoffs of the definition of flat feet. Physical performance was similar between patients with and without bilateral flat feet. The presence of unilateral flat feet was not significantly associated with any outcome measures. These findings indicate that bilateral, but not unilateral, flat feet are associated with worse knee pain. A prospective study investigating a causal relationship between bilateral flat feet posture and knee pain as well as disability would be of particular interest to verify the potential adverse effect of altered foot posture. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2490-2498, 2017., (© 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Adult acquired flatfoot deformity is a debilitating condition typically affecting middle-aged patients. The multiple components include hindfoot valgus, first ray elevation, medial soft tissue compromise, and forefoot abduction. As the foot becomes unbalanced, the deformity progresses with repetitive loading and time. Untreated patients often need significant reconstructions or extensive arthrodesis after arthritis and joint contractures present. Medializing calcaneal osteotomy is the workhorse operation for correction of hindfoot valgus, reliably correcting deformity with a relatively low complication risk. This article reviews indications, techniques, complications, and outcomes for the medializing calcaneal osteotomy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

To compare the treatment efficacy of spastic flatfoot surgery by 2 different surgical methods: nonfusion subtalar arthroereisis using subtalar joint stabilizer (SJS) and Dennyson-Fulford subtalar arthrodesis (D-FSA).A total of 26 cases of ambulant children with cerebral palsy diagnosed as spastic flatfoot were surgically treated from January 2011 to December 2014. Preoperative and postoperative American Orthopedic Foot and Ankle Society-Ankle and Hindfoot (AOFAS-AH) scores, anteroposterior-talocalcaneal angles (ATAs), and lateral talar-first metatarsal angles (Meary angles) of the affected foot were recorded.Among 12 children in the SJS group, the AOFAS-AH scores were median preoperative score of 61 (58-64) versus median postoperative score of 83 (75-92), with significant difference (P < .05). Of the 20 feet treated, only 1 foot developed occasional pain. Postoperative ATA was decreased from preoperative 35° (20°-50°) to 19° (12°-25°); lateral X-ray films showed that the Meary angle was decreased from preoperative 20° (15°-40°) to postoperative 0° (0°-3°). The differences in both findings were statistically significant (P < .05). Fourteen children (22 treated feet) formed the D-FSA group; all demonstrated fusion of the talocalcaneal joint; AOFAS-AH scores were median preoperative score of 61 (58-64) versus median postoperative score of 83 (75-92), with significant difference (P < .05). Only 1 foot had occasional pain. Postoperative ATA was decreased from preoperative 35° (20°-45°) to 16° (12°-25°); lateral X-ray films showed that the Meary angle was decreased from preoperative 19° (10°-40°) to postoperative 2° (0°-5°); the differences in both findings were statistically significant (P < .05).Both nonfusion subtalar arthroereisis using SJS and D-FSA were effective for the surgical treatment of spastic flatfoot, with similar clinical outcomes.

Sacral agenesis is a rare congenital defect which is associated with foot deformities such as congenital talipes equinovarus (CTEV) and less commonly congenital vertical talus (CVT). We report a 3-year-old Caucasian girl who was born with right CTEV and left CVT secondary to sacral agenesis. Her right foot was managed with a Ponseti casting method at 2 weeks, followed by an Achilles tenotomy at 4 months. The left foot was initially managed with a nocturnal dorsi-flexion splint. Both feet remained resistant and received open foot surgery at 10 months producing plantigrade feet with neutral hindfeet. At 19 months, she failed to achieve developmental milestones and examinations revealed abnormal lower limb reflexes. A full body MRI was performed which identified the sacral agenesis. We advocate early MRI of the spine to screen for spinal defects when presented with resistant foot deformities, especially when bilateral., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Pes planovalgus (flatfoot) is a common deformity among children with cerebral palsy. The Milwaukee Foot Model (MFM), a multi-segmental kinematic foot model, which uses radiography to align the underlying bony anatomy with reflective surface markers, was used to evaluate 20 pediatric participants (30feet) with planovalgus secondary to cerebral palsy prior to surgery. Three-dimensional kinematics of the tibia, hindfoot, forefoot, and hallux segments are reported and compared to an age-matched control set of typically-developing children. Most results were consistent with known characteristics of the deformity and showed decreased plantar flexion of the forefoot relative to hindfoot, increased forefoot abduction, and decreased ranges of motion during push-off in the planovalgus group. Interestingly, while forefoot characteristics were uniformly distributed in a common direction in the transverse plane, there was marked variability of forefoot and hindfoot coronal plane and hindfoot transverse plane positioning. The key finding of these data was the radiographic indexing of the MFM was able to show flat feet in cerebral palsy do not always demonstrate more hindfoot eversion than the typically-developing hindfoot. The coronal plane kinematics of the hindfoot show cases planovalgus feet with the hindfoot in inversion, eversion, and neutral. Along with other metrics, the MFM can be a valuable tool for monitoring kinematic deformity, facilitating clinical decision making, and providing a quantitative analysis of surgical effects on the planovalgus foot., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Purpose: To investigate the efficiency of simultaneous correction of moderate to severe hallux valgus deformity and adult-type pes planus., Methods: Twenty cases of moderate to severe hallux valgus complicated with adult-type pes planus in 19 consecutive patients (15 (79%) women, 4 (11%) men; mean age: 44.50 ± 17.13 years, mean follow-up duration: 31.30 ± 17.02 months) were included. Medial calcaneal sliding osteotomy was performed to correct hindfoot valgus, whereas treatments of hallux valgus were case dependent., Results: The mean postoperative hallux valgus angle, intermetatarsal angle, hindfoot alignment angle, and hindfoot alignment ratio were 8.40 ± 5.29°, 4.20 ± 2.54°, 3.09 ± 2.92º and 0.41 ± 0.17, respectively. Although a hallux varus deformity occurred as a postoperative complication in one case (5%), there were no cases of postoperative recurrence., Conclusion: Simultaneous correction of hallux valgus and pes plano-valgus using medial calcaneal sliding osteotomy is an effective technique that reduces recurrence of hallux valgus and increases satisfaction in patients with moderate to severe hallux valgus deformity complicated with adult-type pes planus accompanying hindfoot valgus.

Hallux deformities other than hallux valgus, especially those in the sagittal plane, have not yet been elucidated in the feet of patients with rheumatoid arthritis. The objectives of the present study were to classify rheumatoid arthritis hallux deformity in both the horizontal and the sagittal planes and investigate its relationship with flatfoot. Using a cross-sectional study design, we assessed patients with rheumatoid arthritis (527 feet in 274 patients) using radiographs and classified the deformity patterns of the great toes using cluster analysis. Of the 274 patients, the range of motion in the metatarsophalangeal joint was clinically investigated in 44 (16.1%) patients. The great toes could be divided into 5 clusters according to the characteristic configuration as follows: cluster I (normal type), cluster II (hallux valgus type), cluster III (boutonniere type), cluster IV (boutonniere with hallux valgus type), and cluster V (swan-neck type). Radiographic measurements revealed the characteristic deformities of each cluster, including splayed foot for cluster II; flat foot, metatarsal primus elevatus, and plantar displacement of the proximal phalanx for cluster III; and a mixture of these characteristics for cluster IV. Plantar displacement of the proximal phalanx, which was a specific characteristic of the boutonniere deformity, correlated significantly with the decreased dorsiflexion in the metatarsophalangeal joint. Our classification method revealed the relationship of hallux deformity in the sagittal plane to flatfoot and also demonstrated the usefulness of measuring basal phalanx displacement in predicting the range of motion of the metatarsophalangeal joint., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Unlabelled: This study compared immediate changes in knee and ankle/subtalar biomechanics with lateral wedge orthotics with and without custom arch support in people with knee osteoarthritis and flat feet. Twenty-six participants with radiographic evidence of medial knee osteoarthritis (22 females; age 64.0 years [SD 8.0 years], BMI 27.2 kg/m(2) [4.2]) and flat feet (median foot posture index = + 5) underwent three-dimensional gait analysis for three conditions: Control (no orthotic), lateral wedge, and lateral wedge plus arch support. Condition order was randomized. Outcomes included frontal plane knee and ankle/subtalar biomechanics, and comfort. Compared to the control, lateral wedge and lateral wedge with arch support reduced the knee adduction moment impulse by 8% and 6%, respectively (p < 0.05). However, the lateral wedge resulted in a more everted foot position (4.3 degrees) than lateral wedge plus arch support (3.2 degrees) (p < 0.05). In contrast, lateral wedge plus arch support reduced foot frontal plane excursion compared to other conditions (p < 0.05). Participants self-reported significantly more immediate comfort with lateral wedge plus arch support compared to the control, whereas there was no difference in self-reported comfort between lateral wedge and control. No immediate changes in knee pain were observed in any condition., Clinical Significance: Rather than prescribing lateral wedges to all patients with knee osteoarthritis, those who have medial knee osteoarthritis and flat feet may prefer to use the combined orthotic to reduce loads across the knee, and to minimize the risk of foot and ankle symptoms as a consequence of orthotic treatment. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1597-1605, 2016., (© 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Purpose: During growth, hallux valgus could present associated with flatfoot. Considering the current disagreement about correction of hallux valgus during growth and the lack of reports about simultaneous correction of hallux valgus associated with flexible flatfoot, we present simultaneous treatment of both deformities during growth combining subtalar arthroeresis and SERI first metatarsal osteotomy, reporting results at an average five-year follow-up., Methods: Thirty-two children (64 feet, age range 8-12 years) affected by hallux valgus associated with flexible flatfoot underwent surgical treatment combining SERI first metatarsal osteotomy and subtalar arthroereisis with bioabsorbable endorthotic implant. Clinical evaluation was summarized with AOFAS score, and standard standing radiographs were performed., Results: AOFAS score ranged from 86 ± 2 to 98 ± 2 (hindfoot) and from 80 ± 4 to 98 ± 2 (forefoot). HVA ranged from 21° ± 2 to 5° ± 2, IMA from 14° ± 2 to 7° ± 2, DMAA from 18° ± 2 to 2° ± 2, and Meary's angle from 162° ± 11 to 175° ± 4. Complications included one case of delayed wound healing, inflammatory skin reaction around the outlet of the percutaneous Kirschner wire in two cases, displacement of the endorthotic implant in one case, and a second surgery to replace the implant., Conclusions: SERI osteotomy and subtalar arthroereisis resulted in an effective, technically simple and easily combined approach, with a high rate of good results and low rate of complications at mid-term follow-up. These techniques performed simultaneously represent a viable option in case of hallux valgus associated with flexible flatfoot during growth. Nevertheless, considering the limitations of this study, we believe that a larger case series and a longer follow-up should be desirable.

The role of flexible flat feet (FF) in the development of musculoskeletal symptoms at joints proximal to the ankle is unclear. We undertook an observational study to investigate the relationship between foot posture and the proximal joints in children. It was hypothesised that reduced arch height would be associated with proximal joint symptoms and altered gait kinematics and kinetics particularly in the transverse plane at the hip and knee. Ninety-five children between the ages of 8-15 were recruited into this ethically approved study. Foot posture was classified using the arch height index (AHI). The frequency of knee and hip/back pain was documented, and each child underwent three dimensional gait analysis. Reduced arch height was associated with increased odds of knee symptoms (p<0.01) and hip/back symptoms (p=0.01). A flat foot posture was also significantly associated with a reduction in the second peak of the vertical ground reaction force (p=0.03), which concomitantly affected late stance hip and knee moments. A reduced AHI was also associated with increased pelvic retraction and increased knee valgus in midstance. No kinematic and kinetic parameter associated with a flat foot posture related to increased proximal joint symptoms in the FF group. Children with a flatter foot posture are more likely to have pain or discomfort at the knee, hip and back; however, the mechanisms by which this occurs remain unclear. Treating FF without explicit understanding of how it relates to symptoms is difficult, and further work in this area is required., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Background: Posterior tibial tendon dysfunction is a disabling pathologic flatfoot disorder. Evidence supports the notion that this condition is poorly diagnosed by health-care professionals. In addition, opinion is divided as to the most appropriate assessment and diagnostic techniques used to reflect the progression or stage of the condition. Hence, this study intended to explore the views and opinions of health-care professionals who may be involved in its assessment and diagnosis., Methods: A two-phase sequential mixed methods design was used that combined a questionnaire survey and a focus group interview., Results: The questionnaire data were analyzed using the Kendall levels of concordance and the Cohen kappa statistic, and the focus group data were analyzed using thematic analysis, which led to three main themes: resource implications, scope of practice, and awareness of the condition., Conclusions: This study highlights what may have been suspected previously but that has never been investigated in a structured manner. One approach to the assessment and diagnosis of posterior tibial tendon dysfunction is not necessarily the best, and depending on the clinical teams, different guidance may be required to ensure that patients are receiving the most appropriate and best care.

Background: Patients with adult acquired flatfoot deformity (AAFD) due to posterior tibial tendon dysfunction (PTTD) may require surgery but few reports have evaluated the outcome., Methods: We evaluated 21 patients with a median age of 60 (range 37-72) years who underwent different surgical reconstructions due to stage II AAFD before and 6 and 24 months after surgery by the validated Self-Reported Foot and Ankle Score (SEFAS), Short Form 36 (SF-36) and Euroquol 5 Dimensions (EQ-5D)., Results: The improvement from before to 24 months after surgery was in SEFAS mean 12 (95% confidence interval 8-15), SF-36 physical function 21 (10-22), SF-36 bodily pain 28 (17-38), EQ-5D 0.2 (0.1-0.3) and EQ-VAS 11 (2-21)., Conclusion: Surgery for AFFD due to PTTD results in reduced pain and improved function and health related quality of life. The outcome scores have been demonstrated as useful. It has also been shown, since there is a further improvement between 6 and 24 months after surgery, that a minimum follow-up of 2 years is needed., Level of Clinical Evidence: III - prospective observational cohort study., (Copyright © 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Flatfoot is commonly encountered by pediatric orthopedic surgeons and pediatricians. A paucity of literature exists on how to define a flatfoot. The absence of the medial arch with a valgus hindfoot is the hallmark of this pathology. Flatfoot can be flexible or rigid. This review focuses on the diagnosis and treatment of the flexible flatfoot. Most flatfeet are flexible and clinically asymptomatic, and warrant little intervention. If feet are symptomatic, treatment is needed. Most patients who require treatment improve with foot orthotics and exercises. Only feet resistant to conservative modalities are deemed surgical candidates. The presence of a tight heel cord is often found in patients who fail conservative management., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Intramuscular lengthening of the gastrocnemius and/or soleus (Baumann procedure) is widely used in patients who have cerebral palsy, with several advantages over other lengthening techniques. Tightness of the gastrocnemius or gastrocnemius-soleus complex has been confirmed to be related to flatfoot deformity. The purpose of this study was to evaluate the mid-term results of the Baumann procedure as a part of the treatment of flatfoot with equinus deformity., Methods: We reviewed 35 pediatric and adult patients (43 feet) with flatfoot who underwent the Baumann procedure for the concomitant equinus deformity. The mean duration of follow-up was 39.4 months. Preoperative and follow-up evaluations included the maximal angle of dorsiflexion of the ankle with the knee fully extended and with the knee flexed to 90 degrees, the American Orthopaedic Foot & Ankle Society ankle-hindfoot (AOFAS-AH) scores, and postoperative complications., Results: Preoperatively, the mean angle of passive ankle dorsiflexion with the knee extended was -4.7 ± 2.7 degrees and that with the knee flexed was 2.3 ± 2.5 degrees. At the final follow-up, both values improved significantly by a mean of 13.6 degrees (P < .001) and 9.7 degrees (P < .001), respectively. The average AOFAS-AH scores improved from 56.8 points preoperatively to 72.1 at the final follow-up. Recurrence of equinus was observed in 3 patients (4 feet). There were no cases of overcorrection, neurovascular injury, or healing problems., Conclusions: Our results indicate that the Baumann procedure can effectively and sequentially correct the tightness of the gastrocnemius or the gastrocnemius-soleus complex in patients with flatfoot deformity, without obvious postoperative complications., Level of Evidence: Level IV, retrospective case series., (© The Author(s) 2015.)

We prospectively compared subtalar arthroereisis with lateral column calcaneal lengthening for the treatment of painful flatfeet. Twenty-four feet (mean age of patients 12.8 years) were treated. Kinematic motion analysis, pedobarometry, and radiography were performed, and the Oxford Ankle-Foot Questionnaire for Children was administered for each patient before surgery and at the 1-year follow-up. We found statistically significant improvements in both groups, with no difference in their outcomes. Both groups showed significantly improved hindfoot and midfoot motion and positioning. Hindfoot range of motion was preserved. Radiography and pedobarometry also revealed significant improvements. Subtalar arthroereisis is a valid and potentially less-invasive alternative to lateral column lengthening that merits further investigation.

A clinical records audit of the University of South Australia's podiatry clinic clients attending in 2010 was undertaken to determine prevalence of symptomatic flexible pes planus, presenting reasons and treatment options most frequently used. Analysis of rearfoot measures (resting calcaneal stance position, subtalar joint range of motion) between those prescribed a vertical (heel) or inverted (heel) cast pour and a medial heel (Kirby) skive was undertaken. Of 223 clinical records audited, 50% (111/223) of clients were assessed with flexible pes planus, 77% (86/111) of clients with pes planus presented with back or lower limb pain and 58% (64/111) were prescribed customised foot orthoses. Of 42 prescriptions for customised foot orthoses audited; 64% (27/42) were prescribed a vertical (heel) cast pour, 36% (15/42) an inverted (heel) cast pour and 19% (8/42) received a medial heel (Kirby) skive. Those prescribed a medial heel (Kirby) skive had a more everted resting calcaneal stance position than those that were not (mean -8.6±2.8° vs. -5.5±3.4°, p=0.02). Those prescribed an inverted (heel) cast pour had a greater range of subtalar joint motion than those prescribed a vertical (heel) cast pour (median 36.0±10.0° vs. 29.0±5.0°, p=0.01)., (Crown Copyright © 2015. Published by Elsevier Ltd. All rights reserved.)

Flexible flatfoot is a common malalignment in the paediatric population. Arthroereisis with a calcaneo-stop screw is an effective surgical procedure for treating juvenile flexible flatfoot after conservative measures have been fully exploited. In the present report, we describe the case of a loosening of a calcaneo-stop screw in a 12-year-old youth after excessive trampolining., (© Georg Thieme Verlag KG Stuttgart · New York.)

Children with obesity report musculoskeletal pain more than normal-weight children; this may be linked with literature suggesting children with obesity have higher prevalence of pes planus (flatfoot). To further elucidate whether this relation occurs, we conducted a systematic literature review on the co-occurrence of pes planus and paediatric obesity. Empirical articles published until September 2013 were obtained through an electronic search of MEDLINE and SPORTDiscus; included articles examined the association between body weight and pes planus in children. Thirteen cross-sectional studies of varied designs were identified. Methods used to diagnose pes planus varied between studies: imaging modalities, anthropometric measurements and clinical examination. Across all studies, pes planus prevalence among children with obesity ranged widely from 14 to 67%. Nearly all studies indicated increasing pes planus in children with increasing weight. No studies evaluated pain/complications related to pes planus. Our review suggests increased prevalence of pes planus among children with obesity or increasing weight status. Because of differing methodologies, lack of consensus regarding the pes planus definition, the dearth of investigation into pain/complications and the few existing studies, more research is needed to determine a relation between children's body weight, pes planus and associated effects on pain and function., (© 2015 World Obesity.)

Background: Patients with adult-acquired flatfoot deformity (AAFD) develop peritalar subluxation, which may stem from valgus inclination of the inferior surface of the talus. We hypothesized that patients with AAFD would have an increased valgus tilt of the subtalar joint in the coronal plane compared to controls when assessed with a novel multiplanar weight-bearing imaging (MP-WB)., Methods: Eighteen normal and 36 stage II AAFD patients scheduled to undergo operative reconstruction were evaluated by MP-WB through measuring 3 novel angles of the subtalar joint in the coronal view: (1) angle between inferior facet of the talus and the horizontal/floor (inftal-hor), (2) angle between inferior and superior facets of the talus (inftal-suptal), and (3) angle between inferior facet of the talus and superior facet of the calcaneus (inftal-supcal). Intra- and interobserver reliability were evaluated via intraclass correlation coefficients (ICCs). Differences in angles between AAFD patients and controls were evaluated using Wilcoxon rank-sum test., Results: Intra- and interobserver reliability were excellent for inftal-hor (ICC .942 and .991, respectively) and inftal-suptal (ICC .948 and .989, respectively), and moderate-good for inftal-supcal (ICC .604 and .742, respectively). Inftal-hor and inftal-suptal angles were found to be significantly greater in AAFD patients (P < 0.001) at all 3 locations along the posterior subtalar joint, while inftal-supcal did not demonstrate a significant difference (P = .741). While controls exhibited varus orientation at the anterior aspect of the joint, AAFD patients maintained a valgus orientation throughout., Conclusion: Inftal-hor and inftal-suptal angles provided a reliable means of evaluating the orientation of the subtalar joint axis in AAFD via MP-WB, and showed that the subtalar joint had increased valgus orientation in AAFD compared to controls. This may allow for identification of patients at risk for developing AAFD, and could potentially be used in guiding operative reconstruction., (© The Author(s) 2014.)

Transfer of the flexor digitorum longus (FDL) is indicated to compensate for the loss of posterior tibial tendon (PTT) function in the treatment of adult acquired flatfoot deformity (AAFD). The aim of this study was to determine the effect of PTT resection on pain relief following surgical treatment of stage II AAFD. A retrospective review of patients who underwent surgical treatment for stage II AAFD was performed. Patients were divided into two groups based on whether the degenerated PTT was resected or left in situ. A visual analog scale (VAS) score for pain was recorded for each patient preoperatively. Concomitant surgical procedures and the incidence of postoperative pain were also reported for each group. Deformity correction was assessed with standard weight-bearing radiographs. Thirty-four patients with a mean follow-up of 14 months were included in the study. There was no difference in preoperative VAS pain scores, and patients in both groups demonstrated excellent pain relief postoperatively. Five patients in the PTT resection group and one patient in the PTT in situ group reported lateral-sided foot pain postoperatively. Resection of the PTT did not significantly affect postoperative pain relief. Future prospective studies are needed to determine whether resection of the degenerated PTT is necessary at the time of surgery for stage II AAFD.