import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # Paediatric Flatfoot Examination Paediatric flatfoot examination centers on distinguishing flexible (physiological) flatfoot from rigid (pathological) flatfoot. Examiners expect you to perform the Jack test, assess for tarsal coalition, and understand that most flexible flatfeet in children are normal developmental variants requiring no treatment. ## Quick Reference One-Pager ## Understanding Paediatric Flatfoot **Normal Development:** - All infants appear flat-footed (fat pad, ligamentous laxity) - Medial longitudinal arch develops by age 3-6 years - Adult arch form typically by age 6-10 years - Some children retain flexible flatfoot into adulthood **Key Point:** Flexible flatfoot in children is usually a normal developmental variant, not a disease. **Flexible vs Rigid Flatfoot:** | Feature | Flexible | Rigid | |---------|----------|-------| | Arch on tiptoe | Present (reforms) | Absent | | Jack test | Positive (arch forms) | Negative | | Subtalar motion | Full | Restricted | | Symptoms | Usually none | Often painful | | Treatment | Observation (rarely orthotics) | Investigate cause | ## Observation **Weight-Bearing Views:** **From Behind:** - Hindfoot alignment (valgus is normal in young children) - Too-many-toes sign - Achilles tendon alignment **From Medial Side:** - Medial arch height (absent in flatfoot) - Talar head prominence - Navicular position **From Front:** - Forefoot position - Toe alignment **Compare Both Feet:** - Unilateral flatfoot is more concerning - May indicate coalition or other pathology **Watch Child Walk:** - Foot progression angle (in-toeing/out-toeing) - Heel strike pattern - Push-off phase - Any limp or pain with walking **Running (if age appropriate):** - May show arch more clearly - Observe for fatigue or pain ## Key Special Tests **Assessment:** - Hold calcaneus with one hand - Move forefoot to assess subtalar motion - Compare with other side **Normal vs Restricted:** - Normal: Full inversion/eversion - Restricted: Suggests tarsal coalition or other pathology **Peroneal Spasm:** - Peroneal muscles in spasm with attempted inversion - Strongly suggests tarsal coalition ## Tarsal Coalition Assessment **Clinical Features:** - Rigid flatfoot (fails Jack test, fails tiptoe test) - Restricted subtalar motion - Peroneal spasm - Pain (especially sinus tarsi, lateral foot) - Age typically 8-15 years (when coalition ossifies) **Common Types:** 1. **Calcaneonavicular coalition** (most common, 53%) 2. **Talocalcaneal coalition** (37%) 3. **Other** (talonavicular, calcaneocuboid) **Bilateral in 50%** **Why Coalition Causes Symptoms at Age 8-15:** - Coalition is cartilaginous in early childhood - Progressive ossification restricts motion - Symptoms appear when coalition becomes rigid - Surrounding joints develop degenerative changes ## Associated Conditions **Generalized Ligamentous Laxity:** - Beighton score assessment - Flexible flatfoot more common - Usually benign - Consider syndromes if other features: - Ehlers-Danlos syndrome - Marfan syndrome - Down syndrome **Examination:** - Thumb to forearm - Hyperextension of elbows/knees - Little finger hyperextension - Forward flexion (palms to floor) **Cerebral Palsy:** - Spastic flatfoot - Equinovalgus deformity - Assess tone and reflexes **Charcot-Marie-Tooth:** - May have cavovarus OR planovalgus - Check for muscle wasting - Family history **Spina Bifida:** - Level-dependent deformities - Check skin for stigmata **Congenital Vertical Talus:** - "Rocker-bottom" foot - Rigid from birth - Talar head palpable plantarmedially - Dorsiflexed position **Oblique Talus:** - Less severe than CVT - Correctable with plantarflexion **Accessory Navicular:** - Medial prominence - May be tender - Type II (cornuate) most symptomatic ## Examination Findings by Diagnosis ## Age-Specific Approach **Infants (0-2 years):** - All appear flat-footed (fat pad) - Look for: CVT (rocker-bottom), neurological issues - Usually no intervention needed **Toddlers (2-5 years):** - Arch developing - Flexible flatfoot very common and NORMAL - Check for: Excessive ligamentous laxity, neurological conditions **School Age (5-10 years):** - Arch should be developing - If asymptomatic flexible flatfoot: Reassurance - If symptomatic or rigid: Investigate **Adolescent (10+ years):** - Adult-type arch expected - New onset symptoms may indicate coalition (ossifying) - Investigate rigid or painful flatfoot ## When to Investigate **X-ray Indications:** - Rigid flatfoot - Unilateral flatfoot - Progressive deformity - Pain - Suspected coalition **X-ray Findings:** - **Calcaneonavicular coalition**: Anteater sign (lateral view) - **Talocalcaneal coalition**: C-sign, talar beaking - **CVT**: Talar axis through 1st MT base (lateral view) **CT Scan:** - Best for coalition (especially talocalcaneal) - 3D reconstruction helpful **MRI:** - For cartilaginous/fibrous coalition - Soft tissue assessment ## Treatment Principles **Flexible Flatfoot (Asymptomatic):** - Reassurance to parents - No treatment required - No evidence orthotics change outcome - Activity as tolerated **Flexible Flatfoot (Symptomatic):** - Heel cord stretching if tight - Activity modification - Supportive footwear - Consider medial arch support orthotic - Surgery rarely indicated **Rigid Flatfoot:** - Identify underlying cause - Tarsal coalition: Cast, orthotics, or surgery (resection vs fusion) - CVT: Serial casting then surgery - Neuromuscular: Treat underlying condition ## Summary Presentation ## Examination Sequence 1. **Observe standing**: Arch height, hindfoot alignment, bilateral comparison 2. **Observe gait**: Foot progression, limp, pain 3. **Jack test**: Great toe dorsiflexion - does arch reform? 4. **Tiptoe test**: Arch reformation and heel inversion 5. **Subtalar motion**: Inversion/eversion, peroneal spasm 6. **Silfverskiold test**: Gastrocnemius vs Achilles tightness 7. **Palpation**: Tenderness at sinus tarsi, navicular, coalition sites 8. **Ligamentous laxity**: Beighton score if relevant 9. **Neurological screen**: Tone, reflexes, power if indicated 10. **Compare sides**: Unilateral flatfoot needs investigation ## Examiner Tips