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Foot deformities

Last updated: August 17, 2021

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Foot deformities are a heterogeneous group of congenital and acquired conditions involving structural abnormalities or muscular imbalances that affect the function of the foot. The deformities are classified according to clinical appearance. The most recognizable congenital foot deformity is the clubfoot deformity, which is characterized by plantar flexion of the ankle, inversion of the foot, and adduction of the forefoot. Manipulative treatment of congenital foot deformities, which requires manual repositioning and serial casting, should be initiated immediately after birth. The outcome depends primarily on whether the deformity responds well to manual repositioning (flexible deformities). Resistant deformities often require surgical correction.

Overview of foot deformities [1][2][3][4]
Etiology Characteristics Therapy
Club foot
  • Congenital (common) or acquired (rare)
  • Differential diagnosis: postural clubfoot
  • Manual repositioning and serial casting [5]
  • If manual repositioning is unsuccessful: surgical release of contractures and correction of bone alignment

Equinus deformity

  • Congenital
  • Acquired
  • Attempt manipulative therapy
  • Surgical correction
Pes cavus (high-arch)
  • Congenital or acquired
  • High longitudinal arch
  • Hindfoot varus
Metatarsus adductus
  • In-toeing
  • The deformity may be flexible or rigid
  • X-ray: increased angle between the 1st and 2ndmetatarsal bones
  • Most common cause of in-toeing in children < 1 year of age
  • Rarely requires treatment and resolves spontaneously in > 95% of cases within the first 18 months of life
  • For severe cases (rigid deformity, passive correction impossible): casting

Congenital flat foot

  • Congenital
  • Manipulative treatment immediately after birth
  • Surgery is usually required.
Acquired flat foot
  • Acquired
  • Orthotics
  • Surgery
Splay foot
  • Acquired
  • Orthotics that support the ball of the foot
Calcaneal spur


  • Complete evaluation of feet, knees, hips, and spine
  • Flexible vs. resistant foot deformities
    • Evaluation of foot deformities, according to whether the deformity may be corrected with active (muscular contraction) or passive (manual correction by examining physician) manipulation.
      • Resistant deformity: difficult or impossible to correct → indicates a structural abnormality
      • Flexible deformity: may be easily corrected → indicates a muscular imbalance
  • X-ray: evaluate skeletal deformities

Basic principles of treatment

  • Correctable foot deformities: foot orthotics and manipulative treatment with casting and splinting are usually successful
  • Resistant foot deformities: surgical correction is usually required to reposition structures or relieve muscle contractures

Prompt treatment of congenital foot deformities is vital! Surgery may often be avoided if the manipulation is implemented correctly and consistently. If muscular imbalances are not corrected at an early age, they may result in structural deformities and often require surgery.


  • Definition: Clubfoot is a complex foot deformity that is comprised of five fixed deformities.
  • Epidemiology
    • One of the most common congenital anomalies (∼ 1/1000 births)
    • Bilateral involvement in ∼ 50% of cases
  • Etiology [1]
    • Congenital: most common form
    • Acquired: rare (e.g., secondary to neurological conditions or trauma)
  • Pathogenesis
  • Diagnostics
  • Differential diagnosis: postural clubfoot
  • Treatment
    • Manipulative treatment: the Ponseti-method (manual correction with serial casting )
    • Achilles tenotomy: the equinus foot position may be corrected surgically by lengthening the Achilles tendon with a Z-shaped suture
    • Foot abduction brace (or Ponseti brace)
      • A foot brace consisting of a connecting bar between two footplates, which are adjustable and onto which shoes are attached.
      • Used to treat and prevent relapses in cases of idiopathic clubfoot deformity which have been completely corrected by manipulation, serial casting, and heel cord tenotomy.
  • Complications: pathological strain with ulceration and early onset of arthrosis

Congenital flat feet [8][9]

Functional flat feet

Acquired flat feet [8]

  • Definition: adduction of the forefoot
  • Etiology: : unclear; presents immediately at birth
    • Increased risk in cases of intrauterine malposition
    • Association with hip dysplasia
  • Pathogenesis: a muscular imbalance between the adduction muscles and fibularis muscles is suspected to be the underlying cause
  • Clinical features
    • In-toeing of forefoot
    • Usually painless
    • Cases with high angles of adduction deformity (i.e., increased curvature of the forefoot, increased amount of in-toeing) may present with a medial skin crease over the forefoot
  • Diagnostics
    • Physical examination: See “Flexible vs. rigid foot deformities” above.
    • Gentle palpation of the lateral aspect of the foot → active correction of the deformity → indicates a mild correctable foot deformity
  • Differential diagnoses
  • Treatment


  • Definition: ossification of tendon insertions at the calcaneus bone
  • Etiology: abnormal strain, obesity, foot deformities
  • Pathogenesis: idiopathic; repetitive microtrauma of the tendon insertion has been suggested as an underlying cause
  • Clinical features: localized pain
  • Forms
  • Treatment
    • First-line treatment is conservative
      • NSAIDs
      • Cryotherapy in cases with acute painful inflammation; otherwise thermal therapy (therapeutic ultrasound)
      • Immobilization, sports restriction, orthotics, avoidance of tight, uncomfortable footwear
    • Alternative treatment
      • Radiotherapy:
        • A standardized treatment scheme does not exist.
        • Recommended: single, low-doses of 0.5 Gy (maximum dose of 3–12 Gy)
      • Surgical removal of the spur

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  2. Moeckel E, Mitha N. Textbook of Pediatric Osteopathy. Elsevier Health Sciences ; 2008
  3. Sofka CM, Adler RS, Positano R, Pavlov H, Luchs JS. Haglund's Syndrome: Diagnosis and Treatment Using Sonography. HSS J. 2006; 2 (1): p.27-29. doi: 10.1007/s11420-005-0129-8 . | Open in Read by QxMD
  4. Gore AI, Spencer JP. The newborn foot.. Am Fam Physician. 2004; 69 (4): p.865-72.
  5. Zionts LE, Sangiorgio SN, Cooper SD, Ebramzadeh E. Does Clubfoot Treatment Need to Begin As Soon As Possible?. Journal of Pediatric Orthopaedics. 2016; 36 (6): p.558-564. doi: 10.1097/bpo.0000000000000514 . | Open in Read by QxMD
  6. Pastides P, El-sallakh S, Charalambides C. Morton's neuroma: A clinical versus radiological diagnosis. Foot Ankle Surg. 2012; 18 (1): p.22-24. doi: 10.1016/j.fas.2011.01.007 . | Open in Read by QxMD
  7. StatPearls. Pes Planus. Updated: February 7, 2017. Accessed: February 27, 2018.
  8. Alaee F, Boehm S, Dobbs MB. A new approach to the treatment of congenital vertical talus. J Child Orthop. 2007; 1 (3): p.165-174. doi: 10.1007/s11832-007-0037-1 . | Open in Read by QxMD
  9. Rex C. Clinical Assessment and Examination in Orthopedics. JP Medical Ltd ; 2012
  10. Clubfoot. Updated: September 1, 2014. Accessed: February 18, 2017.