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Journal of the American Academy of Orthopaedic Surgeons 44 Flatfoot is one of the most common conditions seen in the pediatric orthopaedic practice. The first pri- ority in evaluating children with flatfoot is to separate those in whom the natural history of the disorder will result in pain or disability as an adult from those in whom the abnormality has a benign prognosis. A useful method of evaluation is to categorize these patients as having flexible or nonflexible flatfoot, and then as having a painful or nonpainful foot. Calcaneovalgus Deformity Between 30% and 50% of all neonates have a calcaneovalgus deformity of both feet. 1 The foot can be easily dorsiflexed against the tibia, and the heel may be in valgus (Fig. 1, A). The deformity is thought to result from intrauterine position- ing. The anatomy is normal, with no bone subluxations or disloca- tions. The musculotendinous structures are normal in length, and the foot can be easily reposi- tioned. The main element in the differential diagnosis is congenital vertical talus, in which the hindfoot is fixed in equinus and the forefoot is dorsiflexed, rigid, and uncor- rectable. A calcaneovalgus foot is flexible, is not painful, and can easily be plantar-flexed and inverted (Fig. 1, B and C). The deformity generally resolves without treatment; only very rarely is corrective casting necessary. There is no evidence that a calcaneovalgus foot will become a flexible flatfoot. Radiographic imaging is not required to diagnose this condition. Congenital Vertical Talus The diagnosis of congenital vertical talus must be established as soon after birth as possible, as it often requires surgical treatment. The etiology, inheritance, and incidence of this entity are unknown. A familial tendency has been reported by Ogata and Schoenecker, 2 Dr. Sullivan is Don H. OÕDonoghue Professor and Endowed Chair, Department of Orthopedic Surgery and Rehabilitation, University of Oklahoma College of Medicine, Oklahoma City. Reprint requests: Dr. Sullivan, University of Oklahoma College of Medicine, Department of Orthopedic Surgery and Rehabilitation, Suite 2MR2000D, 940 NE 13th Street, Oklahoma City, OK 73126-0307. Copyright 1999 by the American Academy of Orthopaedic Surgeons. Abstract Although the exact incidence of flatfoot in children is unknown, it is a common finding. All children have only a minimal arch at birth, and more than 30% of neonates have a calcaneovalgus deformity of both feet. This condition is not painful and generally resolves without treatment; very rarely is corrective casting necessary. Most children who present to an orthopaedist for evaluation of flatfoot will have a flexible flatfoot that does not require treatment. Nevertheless, the examining physician must rule out other conditions that do require treatment, such as congenital vertical talus, tarsal coalition, and skewfoot. Untreated, congenital vertical talus may result in an awkward gait; manipulation and casting have been tried, but most authors now agree that surgical treatment is required. Although tarsal coalitions can become asymptomatic in adulthood, the anatomy will never be normal. Resection and inter- position of the extensor digitorum brevis is the treatment of choice for calcaneonavicular coalitions; the results of treatment of talocalcaneal coalitions are less predictable. Skewfoot should be treated by manipulation and serial casting as soon as it is detected. In the older child, hindfoot stabilization and realignment of the midfoot may be necessary. Surgical management is rarely indicated for a true flexible flatfoot. A variety of tendon transfers and reconstructive procedures have been advocated, but none has proved uniformly successful. Nor has any of the various types of supports ever been shown to change the arch architecture. Although parents are often concerned about pediatric flatfoot, the child is usually found to be asymptomatic, and no treatment is indicated. In most instances, the best treatment is simply taking enough time to convince the family that no treatment is necessary. J Am Acad Orthop Surg 1999;7:44-53 Pediatric Flatfoot: Evaluation and Management J. Andy Sullivan, MD J. Andy Sullivan, MD Vol 7, No 1, January/February 1999 45 who found that the isolated defect occurred in only 16 of 36 patients in their series. Congenital vertical talus may occur in association with other congenital anomalies, such as myelomeningocele, arthrogryposis, and congenital dislocation of the hip. Findings at surgery include con- tractures of the Achilles tendon posteriorly and the extensor digitorum longus anteriorly, causing dislocation of the navicular onto the neck of the talus and equinus of the heel. Talar abnormalities may include a hypoplastic neck. The talus is in plantar flexion. The extensor reti- naculum may be absent, allowing bowstringing of the tendons. The physical examination of children with this deformity reveals a rigid flatfoot with the heel in valgus. The plantar surface of the foot has a rounded or convex appearance, hence the term Òcongenital rocker-bottom footÓ (Fig. 2). The hindfoot is in equinovalgus with the forefoot abducted and dorsiflexed in the midtarsal region. This deformity cannot be reduced by manipulation. Untreated, patients develop an awkward gait due to a painful rigid foot as well as calluses under the midfoot. Radiographs aid in confirmation of the diagnosis, with the lateral radiograph demonstrating that in dorsiflexion the calcaneus is in equinus, the forefoot is fixed in dorsiflexion, and there is a talonavicular dislocation. These findings do not correct with plantar flexion. If the navicular is ossified, it is dis- located on the dorsal surface of the talus. Manipulation and casting have been tried, but most authors now agree that surgical treatment is required. Casting before surgery may stretch the soft tissues and make skin closure easier. Some authors have recommended a two- stage procedure, 3,4 but the most commonly utilized method is a single- stage procedure through an exten- sile incision. 5,6 The navicular must be reduced onto the talus and fixed with pins. The soft tissues and tendons are lengthened as necessary to achieve this reduction. Surgical treatment requires lengthening of the Achilles tendon and sometimes the dorsiflexors, as well as section- ing of the midfoot capsules. A subtalar fusion is not performed initial- ly, although it may be required if there is recurrence (Fig. 3). There is a high rate of complications, including wound problems, recurrent deformity, loss of motion, and osteonecrosis of the talus. 5,7 Kodros and Dias 7 reviewed the findings in 41 patients (55 feet) who had undergone 32 single-stage release procedures. There were no cases of osteonecrosis. Ten of the feet required reoperation. In any series of patients with congenital vertical talus, the results depend on the presence of underly- ing conditions, such as arthrogryposis and myelomeningocele. Failed reduction in the older child is treated by subtalar fusion. Flexible Flatfoot The largest group of children with a flexible, nonpainful flatfoot present when they begin walking, but the orthopaedist may see them ini- tially well into adolescence. Often, they are brought by concerned parents because of the common lay perception that flatfoot will be associated with pain in adulthood. This has long been reinforced by physicians, who have ordered corrective shoes, inserts, and other devices for the treatment of this benign condition. A B C Fig. 1 This calcaneus foot is easily dorsiflexed against the tibia (A), can assume a normal position actively (B), and is supple and can be inverted (C). Pediatric Flatfoot Journal of the American Academy of Orthopaedic Surgeons 46 Etiology and Natural History Although the natural history of flatfoot is unknown, studies from many countries in which most peo- ple do not wear shoes substantiate the opinion that children with flat feet are generally asymptomatic as adults. 8,9 Harris and Beath con- tributed to the understanding of the natural history of the disorder by noting that in 3,600 Canadian Army recruits the longitudinal arch was of little consequence as a cause of disability and by conclud- ing that a flattened longitudinal arch may be regarded as a normal contour of a strong and stable foot. The development of the arch occurs with growth and is not related to the use of external supports or shoes. Rao and Joseph 8 demonstrated that the prevalence of flatfoot decreased with increasing age. Their study compared children who wore closed shoes or sandals with those who wore no shoes at all. There was a higher prevalence of flatfoot in children who wore shoes compared with those who were unshod. The authors felt that closed-toe shoes inhibited the development of the arch of the foot more than did slippers or sandals. Others have suggested that flatfoot predisposes to the development of bunions. In a study of schoolchildren, Kilmartin and Wallace 10 found that the incidence of bunions was no higher in children with flat feet. While the cause of flatfoot is not known, Basmajian and Stecko 11 con- cluded that the support of the longitudinal arch is ligamentous, with muscle supporting the arch during heavy loading. The shape of the foot is largely due to the bone-ligament complex; muscle is only a dynamic stabilizer. 12 Adults may develop painful flatfoot after loss of posterior tibialis function, but this has been described only once in a child. 13 Evaluation The arch is not present at birth and slowly develops about age 5. 14 Fig. 2 A, Anteroposterior radiograph shows congenital vertical talus in a child with arthrogryposis. On the lateral radiograph in dorsiflexion (B) and the lateral radiograph in plantar flexion (C), the calcaneus is seen to be in equinus, the forefoot is dorsiflexed, and the talus is directed plantarward. The navicular has not yet ossified but is located on the dorsum of the talus. The diagnosis is con- firmed by the plantar-flexion view, on which this relationship is maintained, and the navicular cannot be reduced onto the talus. A B C J. Andy Sullivan, MD Vol 7, No 1, January/February 1999 47 The infant foot has fatty tissue in the arch. By walking age, there may be an arch when the patient is sitting, but it disappears with weight bearing. If the child is able to do a series of prescribed maneu- vers, in most instances the foot will be found to be normal. When the child is asked to stand on tiptoe, the arch usually reconstitutes, and the heel goes into mild varus (Fig. 4). The ability to stand on the heel demonstrates that the heel cord is not excessively tight. The ability to stand on first the outer border and then the inner border of the foot indicates that the musculature of the posterior tibialis, anterior tibialis, and peroneals is functioning normally. Being able to stand on the borders of the feet demonstrates that subtalar motion is normal. The patient should also be examined in the seated position, noting both the strength of the muscles of the foot and the passive range of motion at the ankle and subtalar joint. The shoes should also be examined. Ordinarily, there is heel wear on the lateral aspect. Shoes without heel wear may indicate a tight Achilles tendon. The pronated flexible flatfoot may be associated with the midfoot breakdown that occurs with Achilles tendon tight- ness. Breakdown of the medial portion of the shoe may indicate a flexible foot. Careful evaluation of the gait pattern should be part of the physical examination. The spine and entire lower extremity must be examined for any neuromuscular problem that could cause flatfoot. Radiographs are rarely indicated for an asymptomatic patient. If radiographs are obtained, they should be weight-bearing films. Various angles have been described for the measurement of flatfoot, but none has proved to be reprodu- cible. 15 A line drawn through the talus, navicular, and first metatarsal is ordinarily a straight line. The so- called relaxed talus converts this straight line into an angle with the apex plantar (MearyÕs angle). A plantar-flexed talus early in life will almost always develop normal rela- tionships with further growth and development. Fig. 3 Postoperative radiograph of a patient with congenital vertical talus treated by com- prehensive release and subtalar fusion. The talocalcaneal angle is 29 degrees. Fig. 4 A, Relaxed flatfoot. B, The arch reconstitutes with tiptoe standing, and the heel goes into mild varus. A B Pediatric Flatfoot Journal of the American Academy of Orthopaedic Surgeons 48 Treatment Although parents are often concerned about pediatric flatfoot, the child is usually asymptomatic, and no treatment is indicated (Fig. 5). If the heel cord is tight, it should be stretched manually or with serial casting. If the parents are instruct- ed in stretching, they must be shown how to supinate the foot so that they do not cause further stretching of the midfoot. All manners of treatment have been used, including Òfully corrective orthopaedic shoes,Ó Thomas heels, reversed Thomas heels, custom- molded heel cups, and arch supports. In a study of weight-bearing patterns, Aharonson et al 16 found that use of medial wedges changed the weight-bearing area, making it more nearly normal. In a normal foot, 61% of weight is borne in the posterior weight-bearing area, 35% in the anterior area, and only 4% in the middle. With flatfoot, more of the body weight is carried by the middle weight-bearing area of the foot (17% to 30%). They demonstrated that the optimal correction of the calcaneovalgus and foot ground pressure can be achieved in the standing position by introduc- ing a wedge of the proper height under the medial portion of the heel. The authors claimed that this restores a normal longitudinal arch and reduces pathologic pressure on the middle weight-bearing area in a childÕs flexible flatfoot. Some patients present with symptoms such as aching in the arch, fatigue, and cramps at night. Various types of supports can be tried. Because many children will reject such devices, the least expensive should be tried first, including off-the-shelf inserts. While these modalities may be useful in treat- ing the symptoms in some instances, none has ever been shown to cause either an acute or a perma- nent change in arch architecture. Bleck and Berzins 17 studied the treatment of this condition with either a Helfet corrective heel insert or the University of California Berkeley Laboratory (UCBL) insert. Although the results were encour- aging, interobserver and intraob- server error were not studied. The differences that were demonstrated may be within the range of normal. The best prospective study of corrective devices was performed by Wenger et al 18 at the Texas Scottish Rite Hospital. They used a control group, a group of patients treated with corrective shoes fitted by prescription footwear special- ists, a group who used a Helfet heel cup, and a group who wore a UCBL insert. At a minimum 3-year follow-up, radiographs and clinical examination disclosed no statisti- A B D E C Fig. 5 A, The patient presented at age 3 with a relaxed flatfoot. B, The heel remained in mild valgus at age 5. C, Initial radiograph shows a relaxed talus or talonavicular relationship. D and E, The patient was seen again at age 15 for an unrelated problem. He had a normal arch, although he had received no treatment. J. Andy Sullivan, MD Vol 7, No 1, January/February 1999 49 cally significant improvement in any group and no significant differences between the control sub- jects and the treated patients. The wearing of corrective shoes or devices for 3 years did not influence the course of flexible flatfoot. Cost is an important considera- tion, as custom-molded inserts can cost $150 to $500 and must be re- placed frequently with growth. Many insurance companies will not pay for these, and the parents must pay for them out of pocket. Physi- cians should be wary of prescribing treatments or devices of unproven value solely to pacify parents. The best treatment for this condition is taking enough time to convince the family that it will not cause any problems and no treatment is necessary. For the occasional symptomatic patient or the child whose parents continue to demand treatment, some inexpensive modality, such as off-the-shelf arch supports, can be tried. Surgical management is rarely indicated for a true flexible flatfoot. Although it can alter the shape of the arch, there are no studies to show that it can alter the natural history. The usual indications for surgery are pain that does not respond to conservative care, calluses, and abnormal shoe wear. A variety of tendon transfers and reconstructive procedures have been advocated, but none has proved uniformly successful. In late childhood, some patients will have severe enough symptoms to warrant surgery, but this is a very small group. Rarely should surgery be done before skeletal maturity. If the heel cord is tight, it should be stretched or lengthened. Either fusion of the subtalar joint alone or a more extensive procedure, such as a triple arthrodesis, can change the alignment of the foot. A subtalar fusion alters the mechanics of the hindfoot. The talocalcaneal, talonavicular, and calcaneocuboid joints act in harmo- ny; therefore, fusion of one joint alters the mechanics of the other joints. A triple arthrodesis will realign the foot but eliminates all hindfoot mobility; the long-term result in some patients will be ankle and midfoot arthritis. Osteotomies of the calcaneus and cuneiform can realign the foot while maintaining the normal mobility of the joints. A wedge of bone is taken from the cuboid, and an opening wedge is created in the first cuneiform to receive the wedge. If the forefoot is normal (which is unusual in a flexible flatfoot), a sliding osteotomy of the calcaneus may realign the heel. Calcaneal lengthening has the advantage of correcting the deformity while preserving tarsal motion. 19 Kollias and Kling 20 studied calcaneal lengthening in 24 feet of 14 patients from 3 to 16 years of age. The indications were pain, callosi- ties, or ulcerations that had not re- sponded to shoe modifications or use of orthotic devices. The calcaneus was lengthened by inserting tricortical iliac-crest allograft and internally fixing it in the area between the anterior and middle facets of the calcaneus. At an aver- age follow-up of 42 months, all patients had relief of pain, wore reg- ular shoes, and were not using an orthotic device. Appearance had been improved, and subtalar motion had been preserved. Heel valgus was improved as judged by improvement in the anterior-posterior calcaneal angle. MearyÕs angle and the lateral talocalcaneal angle were improved as well. Arthroereisis (a procedure done to limit motion of the joint) with use of either a bone plug or Silastic has been studied. However, follow-up was insufficient to ensure that Silastic did not cause more problems than the condition its use was intended to alleviate. 21-23 Complications noted in these series include infections, fracture or erosion of the implant, bone spurs, foreign body debris, and giant cell reaction. 24 Given the natural history of flexible flatfoot, which resolves into a functional pain-free foot in adulthood, the risk of these complications is not justified. Accessory Navicular Adolescents may present with a painful prominence on the medial aspect of the foot. There is usually a bony prominence in the region of the navicular (Fig. 6). By palpating the bony prominence and asking the patient to invert the foot against resistance, one can demon- strate that it is in continuity with Fig. 6 Large accessory naviculars (arrows) are visible on this weight-bearing anteroposterior view of both feet. Pediatric Flatfoot Journal of the American Academy of Orthopaedic Surgeons 50 the posterior tibialis tendon. An oblique radiograph usually demonstrates the ossicle medial to the navicular. Erythema, tenderness, and a bursa may be associated with the prominence. When critically reviewed, this is not a cause of flatfoot, nor is it associated with an abnormal arch. 25 It is best to try to persuade the patient to treat the symptoms and alleviate the tendinitis by altering activities or modifying the shoe over the prominence. If the condition is not responsive to this treatment, simple excision can be carried out. 26 Formal rerouting or moving of the posterior tibialis tendon is unnecessary. Patients should be warned that this may be associated with a painful scar and that it is best to avoid surgery if possible. Tarsal Coalition Tarsal coalition is a fibrous, osseous, or cartilaginous union of one or more tarsal bones. It is the result of failure of segmentation, but the cause of that failure has not been established. Although the exact mode of inheritance is unknown, there is a familial tendency. Children with tarsal coalition ini- tially present as they approach skeletal maturity. The history is often one of vague pain in the midtarsal region, usually associated with activity. There may be an increased incidence of ankle sprains. The pain is worse with activity and is relieved by rest. They may have an everted foot and pain with inversion of the foot, the so-called peroneal spastic flatfoot (Fig. 7). The aching is often vague and insidious in onset. On examination, the foot is everted, and there is pain with inversion against resistance. The patient is usually unable to stand on the lateral border of the foot and has decreased subtalar motion. Any condition that involves the subtalar joint, such as trauma, arthritis, or infection, can produce the same symptoms and findings. A series of radiographs consist- ing of anteroposterior and lateral weight-bearing and oblique views will facilitate diagnosis of a calcaneonavicular coalition, which is par- ticularly evident on the 45-degree oblique view (Fig. 8, A). Secondary bone changes, such as talar beaking, broadening or prolongation of the lateral process of the calcaneus (anteater sign), narrowing of the subtalar joint, a concave undersur- face of the talus, and obliteration of the subtalar joint space, may indicate tarsal coalition (Fig. 8, B). Talocalcaneal coalitions are rarely diagnosed on plain radiographs, but are easily demonstrated on axial computed tomographic (CT) images (Fig. 8, C). The section thickness must be no greater than 5 mm, and the scan must include both feet for comparison. Three- dimensional reconstructions are useful, but they are expensive and should be used only in selected cases. Because CT is noninvasive and accurate, it is the procedure of choice for delineation of the anatomy of the coalition when surgery is contemplated. It will also indicate whether the tissue is osseous, cartilaginous, or fibrous. Computed tomography is indicated for all patients with a calcaneonavicular coalition because of the possibility of there being more than one type of coalition in the same foot. Magnetic resonance imaging has also been used to delineate coalitions. However, at this time, it is more expensive than CT and does not delineate osseous anatomy as accurately. Although some studies have shown that coalitions can become asymptomatic in adulthood, the anatomy will never be normal, and the motion of the midtarsal joints is altered. For calcaneonavicular coalitions, resection and interposi- tion of the extensor digitorum brevis is the treatment of choice; good results can be expected. A rectangle of bone measuring approximately 1-cm 2 is resected, and the extensor digitorum brevis is sutured into the defect. A radiograph should be obtained in the operating room to evaluate the adequacy of resection. Talocalcaneal coalitions are more difficult to diagnose, and the results of treatment are less certain. Since the advent of CT scanning, talocalcaneal coalitions have been more easily demonstrated, and more studies have been done on the results of resection. 27,28 The out- come has not been as predictable as with treatment of calcaneonavicular coalition. McCormack et al 29 reviewed middle-facet resection in eight patients (nine feet). At follow-up of at least 10 years, none had a recurrence of symptoms, and all had maintenance of motion. This is the most carefully performed series to date indicating that resection of a middle-facet coalition is generally successful. Fig. 7 This patient had a talocalcaneal coalition. The foot was held in eversion and attempts at inversion elicited pain and resistance. J. Andy Sullivan, MD Vol 7, No 1, January/February 1999 51 The maximal extent of a talocalcaneal coalition that can be safely resected and the recurrence rate compared with calcaneonavicular coalitions are still uncertain. It has been suggested that only by resect- ing the coalition is it possible to restore normal motion and perhaps achieve an asymptomatic foot. This may be possible in young children, but in late adolescence the subtalar joint may already be anky- losed, making resection fruitless. In the past, arthrodesis has been recommended to alleviate pain. As this only completes the coalition and alters the pathomechanics, patients must be advised that triple arthrodesis may result in degenera- tive changes later in life. Cain and Hyman 30 have reported that calcaneal osteotomy to bring the heel out of valgus produces relief, but is indicated only for selected patients. 30 Skewfoot This condition, which is not congenital but develops in the young child, has been variously called an S- shaped foot, a serpentine foot, or a Z foot. Patients present with a flatfoot characterized by hindfoot abductovalgus, metatarsus adductus, and Achilles tendon shortening (Fig. 9). The cause, etiology, and natural history of this rare condition are unknown. It occurs in some patients after cast treatment for metatarsus adductus or clubfoot. The predominant radiographic findings include forefoot adduction with lateral subluxation of the navicular on the talus and heel valgus. Very abnormal shoe wear is noted on the medial side. Calluses occur under the metatarsal heads and the head of the plantar-flexed talus. Operative indications include pain, intractable calluses, and shoe and orthotic problems. Peterson 31 found that nonopera- tive treatment was rarely successful. Patients should be treated by means of manipulation and serial A B C Fig. 8 A, This 45-degree oblique view demonstrates a calcaneonavicular coalition. B, Non-weight-bearing lateral radiograph depicts a talocalcaneal coalition. There is beaking of the talus and loss of definition of the subtalar joint space. C, CT scan illustrates a talocalcaneal coalition in the left foot as viewed from posteriorly. Pediatric Flatfoot Journal of the American Academy of Orthopaedic Surgeons 52 casting as soon as the condition is detected, with particular attention to holding the heel in varus and applying medial pressure on the navicular and lateral pressure on the tarsals. One must be extremely careful during casting that the heel is not placed in further valgus. In older children, Peterson found that hindfoot stabilization and surgical realignment of the bones were necessary. Mosca 32 reported a prospective series of 10 patients with skewfoot deformity treated by calcaneal-neck lengthening (Evans procedure) and medial cuneiform opening-wedge osteotomy (Fowler procedure). Both allograft and autograft were used, and the Achilles tendon was lengthened. There was good clinical correction of the deformity and alleviation of the preoperative indications in 9 of 10 feet. Subtalar motion was preserved, and both allograft and autograft incorporat- ed in less than 2 months with one exception. Summary Flatfoot is a common presenting complaint in the pediatric orthopaedic practice. Most children will have a flexible, nonpainful foot that does not require treatment. Con- genital calcaneovalgus deformity does not require treatment. Rigid or painful flatfoot requires careful evaluation to rule out congenital vertical talus, tarsal coalition, and skewfootÑall of which may require treatment. A B Fig. 9 A,Untreated skewfoot. The forefoot was adducted, and the heel was in valgus. B,Radiograph reveals forefoot adductus with lateral subluxation of the midfoot. References 1.Sullivan JA: The childÕs foot, in Morrissy RT, Weinstein SL (eds): Lovell and WinterÕs Pediatric Ortho- paedics, 4th ed. Philadelphia: Lippin- cott-Raven, 1996, vol 2, pp 1077-1136. 2.Ogata K, Schoenecker PL: Congenital vertical talus and its familial occur- rence: An analysis of 36 patients. Clin Orthop1979;139:128-132. 3.Walker AP, Ghali NN, Silk FF: Con- genital vertical talus: The results of staged operative reduction. J Bone Joint Surg Br1985;67:117-121. 4.Coleman SS, Stelling FH III, Jarrett J: Path- omechanics and treatment of congenital vertical talus. Clin Orthop1970;70:62-72. 5.Seimon LP: Surgical correction of congenital vertical talus under the age of 2 years. J Pediatr Orthop1987;7:405-411. 6.Oppenheim W, Smith C, Christie W: Congenital vertical talus. Foot Ankle 1985;5:198-204. 7.Kodros SA, Dias LS: Congenital vertical talus: Long-term follow-up of single- stage surgical correction. Orthop Trans 1994-1995;18:999. 8.Rao UB, Joseph B: The influence of footwear on the prevalence of flat foot: A survey of 2300 children. J Bone Joint Surg Br1992;74:525-527. 9.Sachithanandam V, Joseph B: The influence of footwear on the prevalence of flat foot: A survey of 1846 skeletally mature persons. J Bone Joint Surg Br 1995;77:254-257. 10.Kilmartin TE, Wallace WA: The sig- nificance of pes planus in juvenile hal- lux valgus. Foot Ankle1992;13:53-56. 11.Basmajian JV, Stecko G: The role of muscles in arch support of the foot: An electromyographic study. J Bone Joint Surg Am1963;45:1184-1190. 12.Smith JW: Muscular control of the arches of the foot in standing: An electromyographic assessment. J Anat 1954;88:152-163. 13.Masterson E, Jagannathan S, Borton D, Stephens MM: Pes planus in childhood due to tibialis posterior tendon injuries: Treatment by flexor hallucis longus tendon transfer. J Bone Joint Surg Br1994;76:444-446. 14.Staheli LT, Chew DE, Corbett M: The longitudinal arch: A survey of eight hundred and eighty-two feet in normal children and adults. J Bone Joint Surg Am1987;69:426-428. J. Andy Sullivan, MD Vol 7, No 1, January/February 1999 53 15.Cook DA, Breed AL, Cook T, DeSmet AD, Muehle CM: Observer variability in the radiographic measurement and classification of metatarsus adductus. J Pediatr Orthop1992;12:86-89. 16.Aharonson Z, Arcan M, Steinback TV: Foot-ground pressure pattern of flexible flatfoot in children, with and without correction of calcaneovalgus. Clin Orthop1992;278:177-182. 17.Bleck EE, Berzins UJ: Conservative management of pes valgus with plantar flexed talus, flexible. Clin Orthop 1977;122:85-94. 18.Wenger DR, Mauldin D, Speck G, Morgan D, Lieber RL: Corrective shoes and inserts as treatment for flexible flatfoot in infants and children. J Bone Joint Surg Am1989;71:800-810. 19.Sangeorzan BJ, Mosca V, Hansen ST Jr: Effect of calcaneal lengthening on rela- tionships among the hindfoot, midfoot, and forefoot. Foot Ankle 1993;14: 136-141. 20.Kollias SL, Kling TF Jr: Calcaneal lengthening for painful pes planus in children. Orthop Trans1993-1994; 17:475. 21.Addante JB, Chin MW, Loomis JC, Burleigh W, Lucarelli JE: Subtalar joint arthroereisis with Silastic silicone sphere: A retrospective study. J Foot Surg1992;31:47-51. 22.Tompkins MH, Nigro JS, Mendicino S: The Smith STA-peg: A 7-year retrospective study. J Foot Ankle Surg 1993;32:27-33. 23.Viladot A: Surgical treatment of the childÕs flatfoot. Clin Orthop 1992;238: 34-38. 24.Kuwada GT, Dockery GL: Complica- tions following traumatic incidents with STA-peg procedures. J Foot Surg 1988;27:236-239. 25.Sullivan JA, Miller WA: The relationship of the accessory navicular to the development of the flat foot. Clin Orthop1979;144:233-237. 26.Bennett GL, Weiner DS, Leighley B: Surgical treatment of symptomatic accessory tarsal navicular. J Pediatr Orthop1990;10:445-449. 27.Olney BW, Asher MA: Excision of symptomatic coalition of the middle facet of the talocalcaneal joint. J Bone Joint Surg Am1987;69:539-544. 28.Scranton PE Jr: Treatment of symptomatic talocalcaneal coalition. J Bone Joint Surg Am1987;69:533-539. 29.McCormack TJ, Olney B, Asher M: Talocalcaneal coalition resection: A 10- year follow-up. J Pediatr Orthop1997; 17:13-15. 30.Cain TJ, Hyman S: Peroneal spastic flat foot: Its treatment by osteotomy of the os calcis. J Bone Joint Surg Br1978; 60:527-529. 31.Peterson HA: Skewfoot (forefoot adduction with heel valgus). J Pediatr Orthop1986;6:24-30. 32.Mosca VS: Flexible flatfoot and skewfoot. Instr Course Lect1996;45:347-354. . Flatfoot Journal of the American Academy of Orthopaedic Surgeons 50 the posterior tibialis tendon. An oblique radiograph usually demonstrates the ossicle medial to the navicular. Erythema, tenderness, and. heel remained in mild valgus at age 5. C, Initial radiograph shows a relaxed talus or talonavicular relationship. D and E, The patient was seen again at age 15 for an unrelated problem. He. the family that it will not cause any problems and no treatment is necessary. For the occasional symptomatic patient or the child whose parents continue to demand treatment, some inexpensive modality, such