CHAPTER 52
Flatfoot
Introduction/Etiology/Epidemiology
• Flatfoot, or loss of the medial longitudinal arch of the foot, is a common condition.
• Although normal in young children, flatfeet are a common concern among parents.
• The (flexible) flatfoot is normal in children up to 6 years due to
— Increased ligamentous laxity
— Medial fat pad normally present at birth
• Rapid development of the medial longitudinal arch occurs during normal growth from 2 to 6 years of age due to atrophy of the medial fat pad and decline in ligamentous laxity.
• Rigid flatfeet may be associated with an underlying etiology such as tarsal coalition or congenital vertical talus.
Signs and Symptoms
• Medial arch of the foot collapses with weight bearing.
• Physiologic (flexible) flatfoot
— Medial arch is reconstituted when non-weight bearing, with toe raise Jack test, or with toe walking (see Chapter 4, Physical Examination, Figure 4-37).
— Usually asymptomatic
• Nonphysiologic (rigid) flatfoot
— Medial arch is not reconstituted when non-weight bearing, with toe raise Jack test, or with toe walking.
— Passive subtalar motion is limited.
— Patients often report activity-related pain around the midfoot or hindfoot.
• Limited ankle dorsiflexion caused by an associated tight Achilles tendon pulls the hindfoot into valgus and leads to an increased flatfoot deformity.
— Evaluate ankle dorsiflexion with the hindfoot in slight inversion to avoid dorsiflexing through the midfoot.
— Silfverskiöld test evaluates for gastrocnemius tightness versus Achilles tendon contracture
■Patients should be able to dorsiflex the ankle at least 10 degrees beyond neutral while the knee is extended, which should then increase when the knee is flexed.
■Limited dorsiflexion with an extended knee but normal dorsiflexion with a flexed knee suggests gastrocnemius tightness.
■Limited dorsiflexion with both an extended and flexed knee suggests Achilles tendon contracture (see Chapter 4
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