A common referral to a pediatric orthopedist is for a foot deformity
that may or may not be symptomatic. Conditions range from benign,
self-resolving, perceived abnormalities involving the forefoot and
toes, to more severe congenital and neuropathic deformities including
clubfoot, congenital vertical talus, and cavus foot. Frequently,
differentiation between a benign, resolving condition and a more
severe pathologic deformity can be made by clinical examination
and level of suspicion. A review of the common disorders, both benign
and pathologic, will be presented to assist in the office evaluation
of pediatric foot conditions.
Medial deviation of the forefoot of an infant, termed metatarsus
adductus, is one of the most common pediatric foot conditions
(Fig. 213-1). Intrauterine positioning—medial
rotation of the foot across the fetal torso—is the presumed
cause of this positional deformity. The “deformity” is
usually flexible and can be passively corrected, in which case no
treatment is actually necessary. Rare cases with severe rigid deformity
may require treatment.1
A: Dorsal view of bilateral metatarsus
adductus. Note the medial deviation of all toes. (Reprinted
with permission from Tachdjian’s Pediatric Orthopaedics,
4th Edition, edited by John A. Herring, Fig. 23-19A.)B: Plantar
view. The lateral border of the foot is curved and “bean
shaped.” (Reprinted with permission from Tachdjian’s
Pediatric Orthopaedics, 4th Edition, edited by John A. Herring, Fig.
Clinically, the forefoot is medially deviated in relation to
the hindfoot. When viewed from the plantar surface, the lateral
border of the foot is curved and appears “bean shaped” (Fig. 213-1B). There may be additional medial
deviation of the great toe and the appearance of a high arch.2 The
deformity can be passively “corrected” if the
examiner grasps the heel and maintains it in the neutral position,
while abducting the forefoot (eFig. 213.1).
Metatarsus adductus is almost always bilateral, although some children
will demonstrate a “windswept” position of the
feet, with one foot internally rotated with metatarsus adductus,
and the opposite externally rotated by the intrauterine position.
Passive correction by abducting the forefoot while maintaining
hindfoot position with counterpressure on the lateral aspect of
the heel. (Reprinted with permission from Tachdjian’s
Pediatric Orthopaedics, 4th Edition, edited by John A. Herring,
Many children will present at walking age with intoeing. Metatarsus
adductus is but one reason the foot progression angle can be deviated
medially—the most common being internal tibial torsion
(ITT). By observing the plantar surface of the foot (Fig.
213-1), the contribution to the intoeing coming from the forefoot can
easily be appreciated and differentiated from ITT. ...