Hallux valgus deformity. Lovell and Winter's Pediatric Orthopaedics, J.B. Philadelphia:Lippincott, 1990, Giannini S, Ceccarelli F, Benedetti MG, Faldini C, Grandi G. Surgical treatment of adult idiopathic cavus foot with plantar fasciotomy, naviculocuneiform arthrodesis, and cuboid osteotomy. Achilles Tendon Rupture Non-operative treatment rehabilitation guidelines 0-2 WEEKS REST (PHASE 1) Goals Rest, recovery and mobilise non-weight bearing safely on crutches Foot & Ankle International. (OBQ06.267) Suggested conservative management of patients with painful pes cavus typically involves strategies to reduce and redistribute plantar pressure loading, with the use of foot orthoses and specialized cushioned footwear. A 57-year-old administrative assistant complains of pain over the bunion on her right foot. Part 1: Prospective cohort study", "The low arch, a protective factor in stress fractures: a prospective study of 295 military recruits", "Prevention of lower extremity stress fractures in athletes and soldiers: a systematic review", American Podiatric Medical Association (APMA), American Academy of Podiatric Sports Medicine (AAPSM), https://en.wikipedia.org/w/index.php?title=Flat_feet&oldid=1123108254, Congenital disorders of musculoskeletal system, Short description is different from Wikidata, Wikipedia articles with style issues from November 2020, Articles with multiple maintenance issues, Creative Commons Attribution-ShareAlike License 3.0, This page was last edited on 21 November 2022, at 21:57. After illness or enforced recumbency, the muscles may temporarily be weak and the arch consequently falls when walking is resumed. (OBQ18.21) Journal of the American Podiatric Medical Association. During the gait cycle, the foot remains locked in hindfoot inversion and forefoot varus throughout the stance phase, causing less stress dissipation. Facing a wall, put your hands against the wall at about eye level. Nerve tension that could be caused by deformities. posterior facet. The absent articulation allowing the FF posture to develop. [11] The talonavicular coverage angle is abnormally laterally rotated in flat feet. (OBQ16.216) Copyright 2022 Lineage Medical, Inc. All rights reserved. Intrinsic muscle develops contractures while the long extensor to the toes, recruited to assist in ankle dorsiflexion, causes cock-up or claw toe deformity. [12]In fact, during early years of gait in toddler years, a child will use their entire foot on the ground for balance. Both tarsal coalition and an accessory navicular can be confirmed by X-ray. Foot and ankle surgery is a sub-specialty of orthopedics and podiatry that deals with the treatment, diagnosis and prevention of disorders of the foot and ankle. Operative tarsal tunnel release is indicated in patients with persistent symptoms who fail nonoperative management. Cheong IY, Kang HJ, Ko H, Sung J, Song YM, Hwang JH. When conservative treatment fails, a series of minimally invasive US-guided procedures can be used as 2nd-line treatments prior to surgery. Crepitus over the anterolateral ankle joint, Palpable tendon snapping over the fibula during ankle dorsiflexion. has 3 facets. A 2007 randomized controlled trial found no evidence for the efficacy of treatment of flat feet in children either from expensive prescribed orthotics (i.e. This is an AAOS Self Assessment Exam (SAE) question. [17] also can present with lateral foot pain from increased weight bearing on the lateral foot. Focusing on the influence of footwear on the prevalence of pes planus, the cross-sectional study performed on children noted that wearing shoes throughout early childhood can be detrimental to the development of a normal or a high medial longitudinal arch. On plain radiography, flat feet can be diagnosed and graded by several measures, the most important in adults being the talonavicular coverage angle, the calcaneal pitch, and the talar-1st metatarsal angle (Meary's angle). As a result, the Plantar calcaneonavicular ligament (spring ligament) and the tendon of the tibialis posterior muscle are stretched to the extent that the individual with pes planus loses the function of the medial longitudinal arch (MLA). A simple test for hindfoot flexibility in the cavovarus foot. [1] This is often observed with the medial arch of the foot coming closer (than typically expected) to the ground or making contact with the ground. (OBQ13.73) Hindfoot varus . Recent ankle aspiration showed no growth on cultures and synovial WBC of 9,800. A 26-year-old active woman is seen for persistent lateral ankle pain. There are no cures or effective courses of treatment to halt the progression of any form of Charcot-Marie-Tooth disease[6], The development of the cavus foot structure seen in Charcot-Marie-Tooth disease has been previously linked to an imbalance of muscle strength around the foot and ankle. Flat feet (also called pes planus or fallen arches) is a postural deformity in which the arches of the foot collapse, with the entire sole of the foot coming into complete or near-complete contact with the ground. (OBQ11.95) Congenital clubfoot is the most common congenital malformation of the foot with an incidence of 1 per 1000 births. Cochrane Database of Systematic Reviews 2007; (4): CD006154. Hallux Valgus, commonly referred to as a bunion, is a complex valgus deformity of the first ray that can cause medial big toe pain and difficulty with shoe wear. What is the next best step in surgical management? The hindfoot forms the heel and ankle. A 47-year-old woman that works as an attorney has a 3-year history of bilateral painful forefeet that is exacerbated with the dress shoes she wears for work. Figure A shows a clinical photograph of her feet. When refering to evidence in academic writing, you should always try to reference the primary (original) source. What is the most appropriate management of the injury shown in Figures A and B? Joints. shoes. A 59-year-old male present with left ankle pain and drainage 3 years after surgery for a traumatic injury to the left ankle. (OBQ07.237) A 65-year-old female well known to your clinic with painful bunions recalcitrant to nonoperative management. 1992;13(1):16. (OBQ20.13) MoscaVS. Orthotics F&A Trauma Ankle Sprains both the superficial and deep layers individually resist eversion of the hindfoot. This arch is supported by posterior tibial tendon, plantar calcanea navicular ligament, deltoid ligament, plantar aponeurosis, and flexor hallucis longus and brevis muscles. Genetics play a strong role with it typically running in families. Chen KC, Yeh CJ, Tung LC, Yang JF, Yang SF, Wang CH. The hallux valgus angle (HVA) is measured at 31 degrees and the intermetarsal angle(IMA) is measured at 16 degrees. Examples being: walking up on tip-toes; walking on the heels; activities to improve the dynamic arch such as walking barefoot on soft sand, flexing the toes (eg picking up a tissue with the toes), rolling a ball under the arch of the foot when seared; encouraging climbing and other gross motor activities. The eversion of the heel has been repeatedly used for determining the posture of the childs foot. Tibial Torsion. The pathophysiology of pes planus can vary greatly depending on whether it is congenital or acquired, and then whether it is flexible or fixed. 2006;96(3):205-11. results. He also reports a history of recurrent ankle sprains when he was younger. Dorsoplantar projectional radiograph of the foot showing the measurement of the talonavicular coverage angle. Physical exam reveals limited ankle dorsiflexion and pain with plantar flexion that is limited to 20 degrees. 2002; 84-A: 62-9, Aktas S, Sussman MD. Ligament laxity is also among the factors known to be associated with flat feet. Thank you. Ankle disarticulation (Symes) amputation through the ankle joint these 3-type of amputations are mainly performed in children to preserve the length of the residual limb and Recommended therapy for lateral hindfoot impingement usually involves surgery, due to the difficulty to stabilize a valgus deformity of the hindfoot with conservative measures such as medial wedge inlays or orthotics. Two-thirds of adults with symptomatic cavus foot have an underlying neurologic condition, most commonly: Charcot-Marie-Tooth (CMT) disease, spinal dysraphism, polyneuritis, Intraspinal tumors,poliomyelitis, syringomyelia, Friedreich ataxia,cerebral palsy, and spinal cord tumors, can cause muscle imbalances that lead to elevated arches[3]. While examining the rest of the lower extremity, both knees are able to hyperextend to about 15 degrees but show no other malalignment. Individuals with rigid flat feet tend to exhibit symptoms such as foot and knee tendinitis, and are recommended to consider surgical options when managing symptoms. results. Medscape, 2019. (OBQ08.10) It remains difficult to conclude if spontaneous physiological arch improvement occurred or the effect of intervention caused the arch improvement. Talar tilt deformity. The subtle cavus foot, "the underpronator," a review. A 55 year-old woman comes to you with 2 months of right foot pain. The talus bone supports the leg bones (tibia and fibula), forming the ankle. has 3 facets. Examination reveals 5 degrees of gastrocnemius equinus contracture, pain with passive plantar and dorsiflexion, but no pain with hindfoot inversion and eversion. Second metatarsalphalangeal joint arthrodesis, Second metatarsal osteotomy (Weil) with extensor tendon and dorsal capsular release, Flexor to extensor tendon transfer (Girdlestone-Taylor), Second metatarsal osteotomy (Helal) with extensor tendon and dorsal capsular release, Second metatarsal head resection with extensor tendon and dorsal capsular release. Femoral Anteversion. In the future, these enzymes may become targets for new drug therapies.[10]. He states he sprained his ankle six months ago, and was treated with bracing and proprioceptive training. J Bone Joint Surg Br. Foot orthotics such as shoe inserts are used to support the arch for foot pain secondary to pesplanus alone or combination with leg, knee, and back pain. She has a history of left ankle septic arthritis requiring arthroscopic irrigation and debridement. A 65-year-old female comes to your clinic reporting a long history of left ankle pain. orthotics and braces are also needed. The biomechanics of pregnancy: A systematic review. Being able to walk on heels demonstrates flexibility of the achilles tendon. Extrinsic causes such as severe ankle sprains, dislocation of hindfoot or ankle, and external trauma (stretch injury, crush injury). anatomic deformity (tarsal coalition, valgus hindfoot) post-surgical scaring. When performing an ankle fusion, the foot should be in: 0 degrees dorsiflexion/plantarflexion, 0-5 degree hindfoot valgus, 5-10 degree external rotation, 0 degrees dorsiflexion/plantarflexion, 0-5 degrees hindfoot valgus, 0 degrees external rotation, 10 degrees dorsiflexion, 0-5 degrees hindfoot valgus, 5-10 degrees external rotation, 0 degrees dorsiflexion/plantarflexion, 20 degrees hindfoot valgus, 5-10 degrees external rotation, 10 degrees plantarflexion, 0-5 degrees hindfoot valgus, 5-10 degrees external rotation, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Bobby Menges Memorial HSS Limb Deformity Course 2021, Strategies for Ankle/Hindfoot Fusion after Trauma - S. Robert Rozbruch, MD, 2019 Orthopaedic Summit Evolving Techniques, Evolving Technique Update: Ankle Arthrodesis & Total Ankle Arthroplasty After Failed Osteochondral Allograft Transplantation: Which Procedure Is The Right One To Use - Kenneth J. (OBQ12.275) Clin Orthop Relat Res. (OBQ07.90) A 45-year-old diabetic male has a Wagner type 3 heel ulcer shown in Figure A that measures 4x2cm and is recalcitrant to debridements and total contact casting for 4 months. J Orthop Sports Phy Ther 1991; 14: 70-74, Williams DS, McClay IS, Hamill J. Arch structure and injury patterns in runners. In flexible pes cavus, midtarsal flexibility complicates the later portion of the stance phase of gait. As part of the assessment process, the physiotherapist can assist in evaluating the gait, gross motor skills and the impact the foot deformity has on functional activities. First metatarsal base and medial cuneiform. Magnetic resonance imaging (MRI) adds further detail and is highly accurate (83%) when investigating space-occupying lesions. A 47-year-old female presents with persistent left great toe pain. Which of the following mechanisms of injury to the ankle is most likely to result in disruption of the superior peroneal retinaculum with subsequent peroneal tendon instability? Since children are unlikely to suspect or identify flat feet on their own, it is important for adult caregivers to check on this themselves. J Bone Joint Surg Am. [11] It is normally up to 7 degrees laterally rotated, so a greater rotation indicates flat feet. He recalls catching his foot on astroturf with a dorsiflexion and inversion moment about his ankle. Every surgery is usually followed by a plaster cast for two to three months. 10 Site Credits [2], According to AAP news and journal gateway, being flexibly flat-footed does not impede athletic performance. A 67-year old female presents with the bilateral foot deformity shown in Figures A and B. Clinically relevant Anatomy [edit | edit source] Clin Orthop Relat Res 1977; 123: 60-2. Lateral Sole Wedge Inserts can be worn in any shoe and beneath existing insoles or prescription orthotics. Gianmarco T., Nicola N., and Guglielmo L.C. Posterior Tibial Tendon Insufficiency (PTTI). 1% (21/2532) 3. Surgical correction becomes increasingly difficult in older children because of secondary changes of the bone. Orthotics - video calls. Patients complain pain , instability , difficulty walking and problems with footwear .The symptoms vary with the degree of deformity . It is less invasive than other techniques, because there is no tendon transfer or bony procedures needed. Of the following procedures below, which did she likely undergo? Foot Ankle Int. In a child younger than 2 years, an extensive release with lengthening of the Achilles tendon and fixation procedure is recommended. What is the best treatment option? The Use of Orthotics and Heel Stabilizers for the Management of Pediatric and Adolescent Flatfoot Deformity. Her clinical image is depicted in Figure A and her radiograph is depicted in Figure B. Original Editors - Uchechukwu Chukwuemeka, Top Contributors - Yoni Baetens, Derycker Andries, Andeela Hafeez, Lauren Heydenrych, Kim Jackson, Vidya Acharya, Lucinda hampton, Admin, WikiSysop, Rachael Lowe, Daniele Barilla, Oyemi Sillo, Kai A. Sigel, Evan Thomas and Scott Buxton. This latter condition is often treated with arch supports.[1]. HVA = 10, IMA = 6, DMAA= 7, congruent joint, HVA = 40, IMA = 20, DMAA = 8, advanced MTP arthritic changes, HVA = 20, IMA = 10, DMAA = 20, congruent joint, HVA = 16, IMA = 12, DMAA = 14, congruent joint, TMT hyper-mobility, HVA = 18, IMA = 12, DMAA = 9, congruent joint. A current radiograph and an MRI of his ankle are shown in Figures A and B, respectively. Counselling on proper footwear, recommendation on motion control shoes, orthotics and braces are also needed. Repeated surgical procedures can be necessary, especially if the deformity is progressive. Which of the following interventions would most likely result in pain relief and the ability to properly fit shoes? (7, 8) They are used most often for excessive pronation or in the case of acquired flatfoot deformity. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Frontal Plane Correction of Hallux Abducto Valgus - Fact or Fantasy? [23], Studies analyzing the correlation between flat feet and physical injuries in soldiers have been inconclusive, but none suggest that flat feet are an impediment, at least in soldiers who reached the age of military recruitment without prior foot problems. The procedure may be performed with an open approach or arthroscopically. Orthotics F&A Trauma Ankle Sprains 20 degrees hindfoot valgus, 5-10 degrees external rotation. Treatment of Complex Ankle and Hindfoot Deformities with AFO Bracing. A radiograph is shown in Figure B. axis of distal phalanx and proximal phalanx, orthoses more helpful in patients with pes planus or metatarsalgia, when symptoms present despite shoe modification, do not perform for cosmetic reasons alone, indicated in very mild disease in young female (almost never), indicated in more moderate disease (IMA > 13), indicated in severe deformity/spasticity/arthritis, only indicated in elderly patients with low functional demands, Treatment - Juvenile and Adolescent Hallux valgus, best to wait until skeletal maturity to operate, can not perform proximal metatarsal osteotomies if, surgery indicated in symptomatic patients with an IMA > 10 and HVA of > 20, consider double MT osteotomy in adolescent patients with increased DMAA, soft tissue procedure alone not successful, goal is to correct an incongruent MTP joint (phalanx not lined up with articular cartilage of MT head). There is little evidence for treatment of asymptomatic, flexible, pediatric flat feet in a child who have no underlying medical issues. Distal first metatarsal osteotomy (Chevron) with lateral metatarsophalangeal joint soft-tissue release (modified Mcbride), Proximal first metatarsal osteotomy (Scarf) with lateral metatarsophalangeal joint soft-tissue release (modified Mcbride), Metatarsal cuneiform fusion (Lapidus) with lateral metatarsophalangeal joint soft-tissue release (modified Mcbride), Lateral metatarsophalangeal joint soft-tissue release (modified Mcbride). Case history of a patient with low back pain and cavus feet. They withstand short-term stresses. This occurs as the fat pad in babies is gradually absorbed, balance improves and skilled movements are acquired. What is the best surgical option to address her deformity? Tarsometatarsal (Lisfranc) - amputation of the forefoot at the tarsometatarsal line. Resisting against recessive pronation and supination forces Rearfoot instability is caused by an extension of the laterally deviated subtalar axis. Treatment of Complex Ankle and Hindfoot Deformities with AFO Bracing. 25% She's tried a rigid-sole running shoe, anti-inflammatories, and orthotics with no relief. (OBQ13.46) A 43-year-old male sustained a left ankle injury 3 years ago. (OBQ07.90) A 45-year-old diabetic male has a Wagner type 3 heel ulcer shown in Figure A that measures 4x2cm and is recalcitrant to debridements and total contact casting for 4 months. [10] Flat feet can also occur in pregnant women as a result of temporary changes, due to increased elastin (elasticity) during pregnancy. Deformity correction and first metatarsophalangeal (MTP) fusion. or D.O. Journal of foot and ankle research. Orthopaedic surgeons are medically qualified, having been through four years of college, followed by 4 years of medical school or osteopathic medical school to obtain an M.D. Radiographs at the time were negative and his pain improved over the next two months. These small changes allow the foot structure to adjust gradually, as well as giving the patient time to acclimatize to the sensation of wearing orthoses. He recalls catching his foot on astroturf with a dorsiflexion and inversion moment about his ankle. Hallux MTP dorsiflexion. This is most common in women over 40 years of age. Which of the following surgical interventions is most appropriate for correction of her deformities? For children with pes planus treatment includes: Advice on appropriate insoles to improve foot position and referral to an podiatrist and an orthotist: in-shoe wedging, foot splints, night stretch splints and cast orthoses. When a peroneal spastic flatfoot is seen, the peroneal tendon which crosses over the subtalar joint often goes into spasm. It is attributed to osseous and ligamentous laxity, immature neuromuscular control and the presence of adipose tissue under the medial longitudinal arch (MLA), making the arch appear flat. 9% (OBQ18.24) (OBQ12.180) The patient has a history of alcoholic induced neuropathy, type 2 diabetes, and had a previous nonunion of his left femur from an unrelated injury. Orthotics F&A Trauma Ankle Sprains both the superficial and deep layers individually resist eversion of the hindfoot. Long-term follow-up of patients undergoing tibialis posterior transfer: is acquired pes planus a complication? Sometimes children are born with flat feet (congenital). A 57-year-old female underwent surgery for severe hallux rigidus. On examination, she has severe pain and stiffness of her great toe, with crepitation. Intrinsic muscle develops contractures while the long extensor to the toes, recruited to assist in ankle dorsiflexion, causes cock-up or claw toe deformity. The classification of the pes planus is based on two aspects: Roughly 20% to 37% of the population has some degree of pes planus, With most cases being the flexible variety. Orthotics F&A Trauma Ankle Sprains Hallux Valgus Hallux Varus DJD & Hallux Rigidus Hindfoot. trauma. There is a functional relationship between the structure of the arch of the foot and the biomechanics of the lower leg. Thank you. A 26-year-old professional ballet dancer presents with insidious onset of right midfoot pain which began 6 months ago. In approximately 50% of cases, clubfoot affects both feet, but it can present unilaterally causing one leg or foot to be shorter than the other. Pes Cavus (Claw Foot) Health Byte. However, when the same subjects performed the exercise while wearing arch supporting orthotics and shoes, the tibialis posterior was selectively activated. Copyright 2022 Lineage Medical, Inc. All rights reserved. A video of his right ankle is found below. [24] No current studies have been successful in fully ascertaining the chronic, long-term detriments to health that are caused by the overexertion (of which is necessary for athletes/soldiers performing with flat feet) and other compensating measures commonly enacted by the body during bipedal movement. Spinal Surgeries Unit - Video Calls. Such a condition can cause severe pain and considerably reduced ability to walk, even with orthoses. Surgical procedures can be broadly categorized into soft-tissue and bony procedures. The 1st TMT joint shows excessive passive plantar and dorsiflexion. (OBQ07.41.1) He was treated with physical therapy and a controlled ankle motion boot for several weeks following the injury with minimal relief. What is the best treatment option for this patient? The eversion of the heel has been repeatedly used for determining the posture of the childs foot. Factors considered influential in the development of pes cavus include muscle weakness and imbalance in neuromuscular disease, residual effects of congenital clubfoot, post-traumatic bone malformation, contracture of the plantar fascia, and shortening of the Achilles tendon [4], Also known as Hereditary Motor and Sensory Neuropathy (HMSN), it is genetically heterogeneous and usually presents in the first decade of life with delayed motor milestones, distal muscle weakness, clumsiness, and frequent falls. The spectrum of associated deformities observed with pes cavus includes clawing of the toes, posterior hind foot deformity (described as an increasedcalcanealangle), contracture of theplantar fascia, and cock-up deformity of the greattoe. 15% (499/3432) One year later she complains of pain at the 2nd metatarsal head and her exam shows a plantar callosity under the 2nd metatarsal head. Also the foot is prone to osteophyte formation at the junction of the metatarsal bases and the cuneiforms. A 56 year-old male underwent a tibiotalar joint fusion six months ago. shoe inserts) or less expensive over-the-counter orthotics. Their primary function is to act as sensory end organs, so when stretched, appropriate muscles are reflexively brought into action. Copyright 2022 Lineage Medical, Inc. All rights reserved. In some cases, surgery can provide lasting relief, and even create an arch where none existed before; it should be considered a last resort, as it is usually very time-consuming and costly. Effective orthotic therapy for the painful cavus foot: a randomized controlled trial. (7, 8) They are used most often for excessive pronation or in the case of acquired flatfoot deformity. Over several weeks, slightly more material is added to the orthosis to raise the arch. stretching and strengthening of tight and weak muscles, debridement of plantar callosities, osseous mobilization, massage, chiropractic manipulation of the foot and ankle, and strategies to improve balance. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Available from: Indy Podiatry. Which of the following structures has been injured? If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. 68% (1722/2532) 4. 10 degrees plantarflexion, 0-5 degrees hindfoot valgus, 5-10 degrees external rotation. Orthotics F&A Trauma Ankle Sprains Hallux Valgus Hallux Varus DJD & Hallux Rigidus Sesamoid Injuries of the Hallux Turf Toe occurs with forefoot fixed and hindfoot or leg rotating. When the angle between the talus and calcaneus is narrowed, the os naviculare moves to a superior position to the cuboid, instead of medial to it. Besides visual inspection of feet and of the treadwear pattern on shoe soles, caregivers should notice when a child's gait is abnormal, or the child seems to be in pain from walking. Neurology. The forefoot pathology produces midtarsal joint supination, that leads to excessive pronation of the rearfoot. This represents a talocalcaneal coalition, which is an abnormal connection between the talus and calcaneus and is thought to cause the flat foot deformity in this case. A 35-year-old man injured his ankle while playing soccer two years ago. These enzymes can break down the constituents of the involved tendons and cause the foot arch to fall. 5% (241/4593) 2. Global activation of the muscles known to support the medial longitudinal arch and the varus with and without resistance. [5], Lateral X-ray of a flat foot with C-sign, which is a bony bridge between the talar dome and sustentaculum tali, in combination with a prominent inferior border of the sustentaculum tali. (SBQ12FA.13) Mid-tarsal (Chopart) - amputation between the talus and the calcaneus proximally and the cuboid and the navicular distally. (OBQ13.264) She is now unable to properly fit shoes on that foot. Symptomatic peroneus brevis tendon tear, tenodesis if tear less than 50%, Symptomatic peroneus brevis tendon tear, tubularization if tear less than 50%, Talar dome osteochondral defect, microfracture if lesion less than 2x2cm, Talar dome osteochondral defect, osteochondral allograft is lesion greater than 2x2cm. A 24-year-old female sprains her ankle playing tennis. What is her diagnosis and corresponding treatment? shoes. However, for the last six months, he has developed persistent ankle pain with intermittent swelling. With the forefoot valgus and the hindfoot varus, increased stress is placed on the lateral ankle ligaments and instability can occur. Double metatarsal osteotomy with sesamoidectomy, Double metatarsal osteotomy with modified McBride, Metatarsophalangeal joint arthrodesis with modified McBride, Tarsometatarsal joint arthrodesis with modified McBride. Thigh-foot angle > 10 degrees internal. On examination, she has severe pain and stiffness of her great toe, with crepitation. followed by specialist training A systematic review and meta-analysis study by Xu, et.al., found that urban sedentary boys, aged 6-9, were frequently diagnosed with flatfeet. Evaluation of the cavus foot for orthopedic treatment. (OBQ13.16) Intrinsic muscle develops contractures while the long extensor to the toes, recruited to assist in ankle dorsiflexion, causes cock-up or claw toe deformity. On examination, she has severe pain and stiffness of her great toe, with crepitation. 1983; 181: 52-63, Coleman SS, Chesnut WJ. 2001a; 16: 341-7, Builder MA, Marr SJ. This is not a true collapsed arch, as the medial longitudinal arch is still present and the windlass mechanism still operates; this presentation is actually due to excessive pronation of the foot (rolling inwards), although the term 'flat foot' is still applicable as it is a somewhat generic term. only indicated if minimal deformity present, transfibular approach often used when deformity present, fusion of the talonavicular joint decreases hindfoot ROM >90%, infection should be cleared prior to placement of definitive internal hardware for arthrodesis, Tibiotalocalcaneal (TTC) fusion with retrograde intramedullary nail, Load-sharing device with improved bending stiffness and rotational stability compared to plate-and-screw constructs, Significant hindfoot bone loss (failed total ankle arthroplasty, failed arthrodesis), lateral transfibular approach allows for dual joint preparation as well as local autograft, neuropathy is greatest risk factor for persistent nonunion with revision of nonunion, injury to superficial peroneal nerve during transfibular approach, adjacent hindfoot arthritis commonly occurs following fusion, isolated hindfoot arthritis due to chronic pes planus is treated with subtalar joint arthrodesis, Posterior Tibial Tendon Insufficiency (PTTI). 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