Systematic examination of flatfoot in children including differentiation of flexible from rigid flatfoot, assessment for tarsal coalition, and identification of pathological versus physiological pes planus.
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.
High-Yield Exam Summary
Normal Development:
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 |
Weight-Bearing Views:
From Behind:
From Medial Side:
From Front:
Compare Both Feet:
Watch Child Walk:
Running (if age appropriate):
Determine if flatfoot is flexible
Medial arch reconstitutes (rises) with great toe dorsiflexion
FLEXIBLE flatfoot - windlass mechanism intact. This is usually physiological.
Ability to detect true positives
Ability to exclude false positives
Assess arch reformation and heel cord length
Arch forms and hindfoot inverts when on tiptoes
Flexible flatfoot with intact tibialis posterior function
Ability to detect true positives
Ability to exclude false positives
Differentiate gastrocnemius from Achilles tightness
Dorsiflexion improves by greater than 10° with knee flexion
Isolated gastrocnemius tightness (may contribute to flatfoot)
Ability to detect true positives
Ability to exclude false positives
Assessment:
Normal vs Restricted:
Peroneal Spasm:
Clinical Features:
Common Types:
Bilateral in 50%
Why Coalition Causes Symptoms at Age 8-15:
Generalized Ligamentous Laxity:
Examination:
| diagnosis | jackTest | tiptoe | subtalar | pain |
|---|---|---|---|---|
| Flexible Flatfoot | Positive (arch forms) | Arch forms | Full motion | None |
| Tight Heel Cord | Positive | May not achieve | Full | Fatigue |
| Tarsal Coalition | Negative | No arch formation | Restricted | Sinus tarsi |
| CVT | Negative | Rigid rocker-bottom | Restricted | Dorsolateral |
| Accessory Navicular | Usually positive | Variable | Usually full | Medial navicular |
Infants (0-2 years):
Toddlers (2-5 years):
School Age (5-10 years):
Adolescent (10+ years):
X-ray Indications:
X-ray Findings:
CT Scan:
MRI:
Flexible Flatfoot (Asymptomatic):
Flexible Flatfoot (Symptomatic):
Rigid Flatfoot:
"6-year-old boy brought by mother concerned about 'flat feet'. Asymptomatic child."
High-Yield Exam Summary