Three-dimensional evaluation of heel raise test in pediatric planovalgus feet and normal feet
Introduction
Parents often seek medical help when their children present with a planovalgus foot. In fact, the prevalence of flexible planovalgus feet in 3- to 6-year-olds is 44%. However, less than 1% of cases is considered pathologic [1] whereas the others are seen as a developmental variation [1], [2]. The younger the children, the more hindfoot valgus is found and boys tend to present with planovalgus feet more often than girls [1]. This foot deformity may also be associated with symptoms such as pain [2]. Although there is a high variability of hindfoot valgus in children, the absence of hindfoot deformity typically is defined in the range 0–5° [1], [3].
The heel raise test is commonly used to clinically test flexibility in planovalgus feet [2], [4], [5]. During this test, the arch, heel valgus/eversion, and prominence of the medial column of the midfoot/talar head prominence are observed. Based on this and other functional tests as well as additional radiographic assessment, different types of pediatric planovalgus feet were identified in past investigations, leading to different treatment recommendations: flexible planovalgus foot, rigid planovalgus foot, congenital vertical talus, tarsal coalition, skewfoot, and planovalgus foot due to other causes [4], [5]. However, in these investigations, the evaluation of specific anatomical characteristics of the planovalgus foot was based on subjective visual observation. As a consequence, treatment recommendations still depend on these subjective observations.
A few studies described planovalgus feet movement based on a 3D gait and foot analysis [6], [7], [8], [9], [10]. These studies give the same results in adults as in children and when using different foot models. The hindfoot in relation to the tibia is more everted and internally rotated in planovalgus feet than in “normal” feet [6], [7], [8]. In relation to the hindfoot, the forefoot is more inverted/supinated and abducted in planovalgus feet than in “normal” feet [6], [7], [8], [9]. In comparison to “normal” feet, the arch is decreased [8], [9]. Kerr et al. [10] demonstrate the position of pediatric planovalgus feet during standing using the Oxford Foot Model. In this study, the hindfoot is more everted, the forefoot more abducted and supinated in severe and in symptomatic planovalgus feet. However, no studies have quantified the flexibility of pediatric planovalgus feet during the heel raise test using an objective 3D foot analysis.
In this study, the primary aim, therefore, was to quantitatively monitor the foot motion characteristics of pediatric planovalgus feet during the heel raise test and thus to establish a feasible method of assessment. A secondary aim was to detect potential differences between painful flexible, painless flexible planovalgus feet, and asymptomatic reference feet to develop specific hypotheses for distinguishing symptomatic from asymptomatic feet by using this functional test. To this end, the Heidelberg Foot Measurement Method (HFMM), an objective 3D foot model [11], was applied with a modified marker set for young children with planovalgus feet.
Section snippets
Subjects
We recruited children aged between 3 and 11 years both from the general public and from the pediatric orthopedic outpatient clinic who presented with planovalgus feet within the last 5 years before recruitment. The goal was to obtain a range of children's feet from “reference” feet, i.e., without any foot deformity, to flexible flatfeet for further analysis. Excluded were patients with neurologic disorders or metabolic diseases. All children were examined (or re-examined) for a flexible
Foot classification
In the static standing trial, an increased medial arch and an increased upright position of medial column were found in the feet classified as reference as compared to planovalgus feet. This also involved a more upright hindfoot in reference feet compared to an increased valgus position of the heel in planovalgus feet. In Table 1 the mean, minimum, and maximum as well as the p-values are presented.
Comparison of methods
The medial arch inclination (HFMM) and medial column inclination (modHFMM) showed similar means
Discussion
Flexibility is an essential criterion in children with a planovalgus deformity for making further treatment recommendations [2]. Thus, clinical testing of flexibility and potential to actively and passively correct the medial arch and hindfoot are well established and commonly used in clinical routine [2], [4], [5]. However, these clinical tests are based on subjective observation and the interpretation of these specific tests varies widely. Therefore, no standardized treatment recommendations
Limitation
Differences in the flexibility patterns detected in this study should be interpreted under consideration of a potential bias between the groups since children with painful flexible planovalgus feet were older than children with painless flexible planovalgus feet.
Furthermore, the technical validation relies in part on data taken from a 21-year-old woman. The reason for choosing an adult was basically due to feasibility issues. An adult was expected to perform the heel raise test and the walking
Conclusion
The flexibility of planovalgus foot deformity in children can be objectively quantified using the modified HFMM. The parameters of this modified HFMM show a high correlation to the parameters of the HFMM and good reliability with a small standard deviation. In the examinations of the 33 children's feet, differing dynamics in planovalgus feet as compared to reference feet could be demonstrated. Planovalgus feet demonstrate a higher range of motion during heel raise. However, they illustrate an
Conflict of interest
All authors declare that they have no financial and personal relationships with other people or organisations which could inappropriately influence this paper.
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Cited by (1)
Cluster analysis to identify foot motion patterns in children with flexible flatfeet using gait analysis—A statistical approach to detect decompensated pathology?
2019, Gait and PostureCitation Excerpt :This shows that irrespective of the classification of the feet may it be radiological or functional, pain is an important factor when indicating surgery. This is supported by another study that did not find any significant differences in the foot kinematics between symptomatic and asymptomatic feet during walking [17] and a heel raise test [29]. Anatomically restoring the footshape and kinematics in flatfeet requires increased muscular activity, making the muscles more susceptible to injury.