POSNA REVIEW ARTICLE
What’s New in Pediatric Flatfoot?
Kathryn Bauer, MD,* Vincent S. Mosca, MD,w and Lewis E. Zionts, MD*
Background: Children with flatfeet are frequently referred to
pediatric orthopaedic clinics. Most of these patients are
asymptomatic and require no treatment. Care must be taken to
differentiate patients with flexible flatfeet from those with rigid
deformity that may have underlying pathology and have need of
treatment. Rigid flatfeet in infants may be attributable to a
congenital vertical talus (CVT); whereas those in older children
and adolescents may be due to an underlying tarsal coalition.
We performed a review of the recent literature regarding eval-
uation and management of pediatric flatfeet to discuss new
findings and suggest areas where further research is needed.
Methods: We searched the PubMed database for all papers re-
lated to the treatment of pediatric flatfoot, tarsal coalition, and
CVT published from January 1, 2011 to December 31, 2014,
yielding 85 English language papers.
Results: A total of 18 papers contributed new or interesting
findings.
Conclusions: The pediatric flexible flatfoot (FFF) remains poorly
defined, making the understanding, study, and treatment of the
condition extremely difficult. Pediatric FFF is often un-
necessarily treated. There is very little evidence for the efficacy of
nonsurgical intervention to affect the shape of the foot or to
influence potential long-term disability for children with FFF.
The treatment of tarsal coalition remains challenging, but short-
term and intermediate-term outcome studies are satisfactory,
whereas long-term outcome studies are lacking. Management of
the associated flatfoot deformity may be as important as man-
agement of the coalition itself. The management of CVT is still
evolving; however, early results of less invasive treatment
methods seem promising.
Level of Evidence: Level 4—literature review.
Key Words: review, pes planus, flatfoot, tarsal coalition, con-
genital vertical talus
(J Pediatr Orthop 2015;00:000–000)
From the *Department of Orthopaedics, David Geffen School of
Medicine at UCLA, Orthopaedic Institute for Children, Los
Angeles, CA; and wDepartment of Orthopaedics and Sports Medi-
cine, Seattle Children’s Hospital, University of Washington School
of Medicine, Seattle, WA.
None of the authors have received financial support for this study.
The authors declare no conflicts of interest.
Reprints: Lewis E. Zionts, MD, Orthopaedic Institute for Children, 403
West Adams Boulevard, Los Angeles, CA 90007-2664. E-mail:
LZionts@mednet.ucla.edu.
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J Pediatr Orthop  Volume 00, Number 00, ’’ 2015
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C hildren are commonly referred to an orthopaedic
surgeon for evaluation and management of a flatfoot
deformity. We performed a review of the recent literature
regarding evaluation and management of pediatric flat-
feet to discuss new findings and suggest areas where fur-
ther research is needed.
METHODS
We searched the PubMed database using the fol-
lowing terms: pediatric flatfoot, tarsal coalition, and
congenital vertical talus (CVT). We reviewed only papers
published in English from January 1, 2011 to December
31, 2014.
RESULTS
Eighty-five papers were found. The authors identi-
fied 19 of these papers as having contributed important
new findings.
DISCUSSION
Flexible Flatfoot (FFF)
For a condition that has been determined to ac-
count for more consultations to pediatric orthopaedic
clinics than any other, the pediatric FFF remains poorly
defined, making the understanding, study, and treatment
of the condition extremely difficult.
In a Cochrane Review, Evans and Rome1 scruti-
nized the literature on FFF in children in regard to the
epidemiology, foot development, etiology and associated
issues, diagnosis, nonsurgical management, and surgical
interventions. They concluded that the very definition of a
flatfoot is debatable. The available prevalence estimates
are limited by variable sampling, assessment measures,
and age groups and, therefore, result in disparate findings.
The authors noted that the literature suggests that the
FFF reduces with age, and that most affected children and
adults are asymptomatic. Joint hypermobility and in-
creased body weight may increase flatfoot prevalence, in-
dependently of age. Furthermore, the review suggested
that the pediatric FFF is often unnecessarily treated, and
that there is very little evidence for the efficacy of non-
surgical intervention to affect the shape of the foot or to
influence potential long-term disability for children with
FFF. The authors note that inexpensive, generic foot
orthoses can provide good positional support and relieve
symptoms in those feet with activity-related pain. Cus-
tomized foot orthoses should be reserved for children with
foot arthritis, unusual foot morphology, or unresponsive
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Bauer et al
cases. There is no evidence that supports the use of sur-
gical correction of the typically asymptomatic and FFF in
children. Surgery is only indicated at the failure of thor-
ough conservative management.
A related critical review article from the same in-
stitution2 confirmed that there is very little evidence for
the effectiveness of nonsurgical intervention for pediatric
FFF. All articles reviewed were assessed using the Quality
Index score, which uses a structured checklist to access
the validity of clinical trials. They found only 13 articles,
among the 429 published between 1970 and 2011 on the
efficacy of nonsurgical interventions for pediatric FFF,
that met the criteria for quality evaluation; and the mean
Quality Index score was only 35%. The authors listed a
number of methodological limitations of the studies, in-
cluding the lack of a control group, inconsistent methods
of diagnosis, small sample sizes, variable recruitment
ages, failure to use valid and reliable outcome measures,
and dissimilar follow-up periods. In addition to address-
ing these shortcomings, the authors recommended that
future research efforts include longer, prospective follow-
up studies to allow identification of effective inter-
ventions.
Historically, several authors have reported a greater
body mass index (BMI) in subjects with FFF. Tenenbaum
et al3 looked at the relationship between FFF and BMI,
body height, and sex in 825,964 generally healthy 16 to
19-year-old Israelis who presented to a military recruiting
center for a mandatory comprehensive medical evaluation
since 1998. Acknowledging that the diagnosis of mild and
severe pes planus in their study was subjective, they found
a greater prevalence of FFF in males than females. FFF
was associated with increased BMI and shorter body
height for all grades of severity and in both sexes.
Imaging
Not all flatfeet are the same. Bourdet et al4 identi-
fied 4 patterns of pes planovalgus in a study of 65
standing AP and lateral foot radiographs in 35 children
aged 7 to18 years who were diagnosed with idiopathic or
neurological flatfoot. Subtalar pes planus is characterized
by marked subtalar valgus and longitudinal sag pre-
dominantly at the talonavicular joint. Midtarsal pes
planus has marked midtarsal abduction and sag pre-
dominantly at the cuneonavicular joint without subtalar
valgus. Mixed pes planus, the most common pattern,
combines subtalar valgus, midtarsal abduction, and sag at
both the talonavicular and cuneonavicular joints. Pes
planocavus manifests as sag of the medial arch and cavus
deformity of the lateral arch. The authors concluded that
their classification system is helpful for the accurate as-
sessment of the site(s) of deformity that can be used to
determine the best surgical technique for a symptomatic
flatfoot, although they have not validated their treatment
algorithm.
Surgical Techniques
The technique of arthroereisis involves the insertion
of a metallic or synthetic implant in the region of the sinus
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J Pediatr Orthop  Volume 00, Number 00, ’’ 2015
tarsi to correct alignment of the subtalar joint in children
with FFF. As reported in the previously highlighted re-
view by Evans and Rome,1 the indication for this proce-
dure remains controversial.
De Pellegrin et al5 reported an uncontrolled, retro-
spective study of 732 subtalar extra-articular screw ar-
throereisis procedures performed in 485 children between
the ages of 5 and 18 years. Only 11% of the patients
reported pain preoperatively. The justification for surgery
in this study seemed to be the foot shape itself, and the
ease of performing the minimally invasive procedure. Of
note is that 2% of the patients reported pain post-
operatively. It is not clear from the manuscript how many
of those patients had pain preoperatively.
Perhaps the most commonly used procedures to
correct an intractably symptomatic FFF are the anterior
and posterior calcaneal osteotomies. Moraleda et al6
compared the calcaneo-cuboid-cuneiform (triple C) os-
teotomies procedure that was developed at the authors’
institution, with the calcaneal lengthening osteotomy
(CLO) for the treatment of symptomatic FFF. The study
compared 30 feet (21 patients) in the triple C group to 33
feet (21 patients) in the CLO group. The average follow-
up for the CLO group was nearly twice that of the triple C
group (5.3 vs. 2.7 y). The necessary additional osseous
and soft tissue procedures of the CLO (CC joint fixation,
medial soft tissue reefing, peroneus brevis lengthening,
tendo-Achilles lengthening) were only performed between
18% and 38% of the time. That said, the authors found
no difference in subjective or objective clinical outcomes
between the study groups, and the CLO group achieved
significantly better alignment at the talonavicular joint
than the triple C group. The authors acknowledged that
CC joint subluxation could have been a surgical mistake
instead of a fault of the CLO technique and that the
subluxation did not affect the outcome.
Tarsal Coalition
A tarsal coalition is often the cause of foot pain in
children and adolescents who present with a rigid flatfoot
deformity. Talocalcaneal (TC) and calcaneonavicular
(CN) are the most common types. These patients are
typically asymptomatic in early childhood, and generally
present with activity-related hindfoot and midfoot pain in
early adolescence. When the patient is not responsive to
nonoperative treatment, surgery may be considered.
Clinical Outcome
The long-term outcome of surgically resected coa-
litions is not well established in the literature. Outcomes
are thought to vary with the type and extent of the bar as
well as the amount of subtalar valgus deformity present.
Mahan et al7 mailed outcome questionnaires to patients
who had undergone surgical excision of a tarsal coalition.
Sixty-three of 101 patients (63.4%) responded at an
average of 4.6 years after surgery. TC coalitions were
present in 20 patients; CN coalitions were present in the
other 43 patients. Five patients (5%) required additional
surgery after initial coalition resection. No limitation of
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J Pediatr Orthop  Volume 00, Number 00, ’’ 2015
activity due to foot pain was reported by 46 patients
(73%). The authors found no difference in the self-re-
ported outcomes between those treated for a TC and
those treated for a CN coalition. As well, in patients with
TC coalitions there was no difference in outcomes be-
tween those with <50% of the posterior facet involved
compared with those where >50% was involved.
Longer term follow-up was reported by Khoshbin
et al8 who retrospectively evaluated 32 tarsal coalition
resections in 24 patients using clinical examination and
self-reported functional outcome questionnaires. Con-
comitant calcaneal osteotomies were performed in 2 feet.
The patients were followed for a mean of 14.4 years after
surgery. The authors reported that the patients had little
pain and few functional limitations. Patients with resected
CN and TC coalitions reported similar function and pain
on self-reported outcome questionnaires. In contrast to
earlier studies, excellent long-term functional outcomes
were found in patients who had TC coalitions involving
greater than 50% of the posterior facet. As well, patients
in the TC group with >16 degrees of hindfoot valgus and
those with <16 degrees had similar outcomes scores.
Imaging
As a tarsal coalition can sometimes be cartilaginous
or fibrous, plain radiographs and computed tomography
(CT) may not always be definitive. Guignand et al9 de-
scribed a series of 19 feet with a CN coalition in 14
children. The authors reported that plain radiographs
were not conclusive in 10 feet (53%), and these patients
underwent further imaging including either bone scan,
CT, or magnetic resonance imaging (MRI). The authors
claimed that bone scan missed the diagnosis in 3 of 7 feet;
CT missed the diagnosis in 4 of 11 feet. Twelve feet were
assessed by MRI that confirmed the diagnosis in all in-
stances. The authors concluded that MRI was the most
effective imaging modality to assess CN coalitions.
A C-sign of Lateur may be present on a lateral ra-
diograph of the foot in patients who have a TC coalition.
The C-sign is formed by the medial outline of the talar
dome, and the posteroinferior outline of the sustentac-
ulum tali (Fig. 1). This line may seem continuous or in-
terrupted. Moraleda et al10 performed a retrospective
FIGURE 1. The C-sign of Lateur. The sign is a C-shaped line
formed by the medial outline of the talar dome and the in-
ferior outline of the sustentaculum tali (arrows). Its presence
suggests the presence of a tarsal coalition tarsal coalition.
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Pediatric Flatfoot
review of lateral radiographs of 88 feet in patients with a
TC coalition confirmed by CT scan, and 260 patients with
FFF. The authors found that a “true” C-sign (defined as
complete, or having a linear interruption with rarefaction
of the edges) had a prevalence of 41% in cases of TC
coalition versus only 0.4% of flatfeet. They concluded
that a “true” C-sign indicates the presence of a coalition,
whereas the other types of interrupted C-signs were much
more likely to be related to flatfoot deformity than to a
coalition.
Surgical Techniques
Assessing the adequacy of a TC coalition resection
while in the operating room can be difficult. Kemppainen
et al11 compared coalition resection in 14 feet using in-
traoperative CT scan with 12 feet in which this imaging
modality was not used. The quality of resection was de-
termined by 2 pediatric orthopaedic surgeons, who were
blinded as to how the coalition resection was performed,
by comparing preoperative and postoperative CT scans.
The resection quality was deemed better in the intra-
operative CT group. As well, the use of intraoperative CT
altered surgical decision making in 3 feet (21%). Both
groups showed similar improvement in pain at last fol-
low-up. Larger, prospective studies would be useful to
show whether improved clinical outcomes can justify the
increased cost and radiation exposure using this imaging
modality.
Mosca and Bevan12 retrospectively evaluated 13
painful TC coalitions in 8 patients who had undergone a
CLO with gastrocnemius or Achilles tendon lengthening
for correction of deformity with or without resection of
the coalition. Five patients underwent isolated CLO due
to large coalitions averaging 89% of the posterior facet.
One patient with bilateral large coalitions underwent
concomitant coalition resection and CLO. Two other
patients had undergone earlier coalition resection and
underwent CLO later when pain recurred. The clinical
outcome scores improved in all cases. The authors con-
cluded that restoring the hindfoot alignment can improve
symptoms in cases of resectable as well as nonresectable
TC coalitions with preoperative hindfoot valgus >16
degrees, and that resection of the coalition is not man-
datory to have good results with CLO.
Less invasive methods of coalition resection have
been proposed, including percutaneous and arthroscopic
resection techniques. El Shazly and Abou El Ela13 used a
percutaneous method to resect CN coalitions involving 12
feet in 9 patients. Under C-arm guidance, they used a 4.5-
cannulated drill bit followed by a burr to resect the bar,
followed by placing a rolled Teflon sheet as interposition
material. The patients were followed for a mean of 26.4
months, and showed improved functional outcome. The
authors reported no complications or recurrences at latest
evaluation. Knorr et al14 reported arthroscopic resection
of CN coalitions in 3 children. Two portals were estab-
lished, a viewing portal that is posterior to the antero-
lateral process of the calcaneus and dorsal to the angle of
Gissane, and a working portal distal to the calcaneal
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Bauer et al J Pediatr Orthop  Volume 00, Number 00, ’’ 2015

process and lateral to the extensor digitorum longus.
They did not clearly state whether any interposition ma-
terial was used. Clinical outcome scores for the 3 patients
improved from 58 to 91, and there were no recurrences at
1 year. Quicker recovery and a smaller scar are cited as
advantages.
Congenital Vertical Talus
A CVT is a rigid flatfoot deformity that presents at
birth that is characterized by a fixed dorsal dislocation of
the navicular on the head of the talus. Traditionally, this
deformity was managed by cast applications followed by
extensive soft tissue release. More recently, minimally
invasive approaches, known as the “Reverse Ponseti” or
“Dobbs” technique, have been described (Fig. 2).
Open Surgical Treatment
Ramanoudjame et al15 evaluated the results of
midtarsal release and open reduction to manage 22 pa-
tients with 31 CVT followed for a mean of 11 years
(range, 2 to 21 y). In 9 patients (15 feet) the deformity was
isolated. Surgery was performed at a mean age of 33
months (range, 10 to 120 mo). The patients generally
showed good functional results. The authors noted that
subtalar motion was reduced, and the medial longitudinal
arch was flat in every case. However, all patients were
able to wear ordinary shoes. Only 6 feet (19%) showed
persistent talonavicular subluxation. Five feet (16%) re-
quired further surgery. No talar avascular necrosis was
seen. This article suggests that surgical management,
which may be needed in older patients with CVT or those
patients who fail minimally invasive approaches, may
yield acceptable results with fewer complications than
have been reported in the past.
Cast and Minimally Invasive Surgical Treatment
Chalayon et al16 reported management of 15 pa-
tients (25 feet) with nonisolated CVT (associated with
spina bifida, distal arthrogryposis, and other genetic dis-
orders) who were followed for a minimum of 2 years. The
feet underwent an average of 5 manipulations and casts.
Talonavicular pinning was performed through a small
incision in the talonavicular joint in 5 feet. Selective
capsulotomies of the talonavicular joint and anterior
subtalar joint were performed in 20 feet. All patients had
a percutaneous Achilles tenotomy. Relapse was noted in 5
feet (20%) that required further treatment. No subtalar
stiffness was noted at latest follow-up evaluation.
Wright and colleagues17 reported management of 13
patients (21 feet) with CVT who were followed for a mean
of 36 months (range, 8 to 57 mo). Six of the patients (9
feet) had teratologic CVT. They reported a median of 8
manipulations and casts to adequately improve the
alignment of the talonavicular joint. In 7 feet (33%) a
limited capsulotomy was needed to achieve final reduc-
tion. Initial correction was obtained in all. Overall, re-
lapse was seen in 10 feet (48%): 4 of 12 feet (33%) in the
idiopathic group. None of those with relapse had limited
capsulotomy and open reduction. The authors postulated
that including a limited capsulotomy at the initial oper-
ation may reduce the risk of relapse.
The upper age limit for successful management of
CVT using techniques involving minimal surgery is not

FIGURE 2. Minimally-invasive treatment of congenital vertical talus (CVT). A, Lateral radiograph in neutral position. B, Forced
plantarflexion radiograph showing the long axis of the talus does not align with the first metatarsal indicating the presence of a
CVT. C, Force plantarflexion radiograph after 6 manipulations and cast applications. D and E, Appearance after percutaneous
pinning of talonavicular joint. F and G, AP and lateral radiographs taken at age 2 years.

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J Pediatr Orthop  Volume 00, Number 00, ’’ 2015
well established. Aslani et al18 treated 15 feet with CVT in
10 patients whose age ranged from 1 month to 9 years of
age. Half of the patients had teratologic CVT. They used a
minimally invasive approach that included serial manipu-
lation and cast application, limited open reduction of the
talonavicular joint, and Achilles tenotomy. After a mean of
2 years (18 to 36 mo) they reported pain-free, flexible, and
plantigrade feet in all cases, including the feet of 4 patients
aged 5 to 9 years. Although the follow-up was short, the
authors suggested that older patients with CVT can be
managed with a minimally invasive technique.
Imaging
It is important to differentiate CVT from a marked
FFF (oblique talus) because the treatment differs.
Supakul et al19 suggested that there are limitations in
interpreting plain radiographs of the foot in infants due to
variable ossification patterns of the talus. They described
the use of ultrasound to help differentiate CVT from
flexible flatfeet in 13 infants below 6 months of age. On
ultrasound, 10 feet were noted to have CVT confirmed at
surgery. Advantages of this modality are that it directly
depicts the cartilaginous talus and navicular and does not
use ionizing radiation.
Summary
The pediatric FFF remains poorly defined, making
the understanding, study, and treatment of the condition
extremely difficult. Pediatric FFF is often unnecessarily
treated, and there is very little evidence that nonsurgical
intervention can affect the shape of the foot or influence
the potential long-term disability.
The treatment of tarsal coalition remains challeng-
ing, but short-term and intermediate-term outcome
studies show promising results of surgical resection.
Longer term outcome studies are needed to help confirm
these findings. Management of the associated flatfoot
deformity may be as important as management of the
coalition itself.
The management of CVT is still evolving; however,
early results of less invasive treatment methods seem
promising. Because these techniques are relatively new, we
must await the appearance of longer term outcome studies.
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Pediatric Flatfoot
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