HPI: The patient is a mentally challenged 16-year old male who presents with significant pain and deformity associated with a severe bilateral pes planus deformity. The patient has a complicated medical history, including an undiagnosed genetic syndrome manifesting with severe cognitive impairment, bilateral lower extremity deformity, and soft tissue contractures. Both extremities are affected, however the right is more symptomatic. The patient has previously been treated at an outside facility for this complaint and underwent bilateral foot “osteotomies” in an attempt to correct his significant deformity. However, the patient’s mother relates that his feet have become progressively worse over the last year. The patient’s mother relates that he has complained of increasing pain over the last six months, and states that he demonstrated a reduction in his physical activity because his “feet hurt.”

by Ryan Fitzgerald, DPM
PRESENT RI Associate Editor
Washington Hospital Center
Washington, DC

VS: Temp: 98.1, HR: 82, RR: 18, BP: 104/82

PMH: Undiagnosed genetic syndrome, spastic dysplasia, scoliosis

PSH: bilateral percutaneous TAL, bilateral foot osteotomies (performed OSH), R Varus derotational osteotomy (VDRO) femoral osteotomy

FMH: HTN, Breast CA

MEDS: Baclofen, Tylenol,

ALL: NKDA

SOCIAL: lives at home with family and caregiver, he socializes as part of group therapy three times a week.

RADIOGRAPHS: Radiographs obtained demonstrate three views of the right foot. AP and Oblique views of the right foot demonstrate significant abduction of the forefoot on the rear foot (Fig.1 ). A lateral view of the right foot demonstrates significant plantarflexion of the talar head, decreased calcaneal inclination angle, elevation of the first metatarsal, and flexion contracture of the digits (Fig. 2).

Figure 1: AP and Oblique radiographs demonstrate significant abduction of the forefoot on the rearfoot. The tarsals appear somewhat displastic, and there is an increase in the talonavicular coverage angle.

Fig. 2: A lateral of the right foot demonstrates significant plantarflexion of the talar head with an increase in Meary’s angle, decreased calcaneal inclination angle, elevation of the first metatarsal, and flexion contracture of the digits. There is a rocker-bottom foot type developing, with collapse of the midfoot.

PHYSICAL EXAM: Upon physical exam, the patient is noted to be neurovascularly intact with pedal pulses palpable and graded +2/4 bilaterally. There is bilateral pes planus deformity noted, worse on the right than the left, with collapse of the medial arch and hyperkeratotic tissue formation along this location. (fig. 3). The patient demonstrates a dorsiflexed 1st metatarsal, with fixed plantar flexion of the hallux, and more flexible contracture of the lesser digits. The hallux is flexed in a position that is underlapping the second digit (fig. 4). The patient demonstrates a calcaneal valgus rearfoot position, and shows soft tissue atrophy along the lateral aspect of the foot in the area of the sinus tarsi. Muscle strength is graded +5/5 in all muscle groups tested, and an equinus deformity was note at the ankle. Deep tendon reflexs were noted to be hyper-reflexive at the Achilles and patella tendons, bilaterally.

Figure 3: There is collapse of the medial arch with dorsiflexion of the 1st ray and fixed flexion contracture of the right hallux. (photograph courtesy of Dr. Sarah M. Fitzgerald, DPM)

Figure 4: There is soft tissue atrophy noted in the area of the sinus tarsi, and the right hallux is fixed in an underlapping position in relation to the second digit. In this photo you can appreciate the degree of calcaneal valgus as compared to the long axis of the distal tibia. (photograph courtesy of Dr. Sarah M. Fitzgerald, DPM)

Figure 5: There is atrophy noted in the area of the sinus tarsi. The patient demonstrates flexible flexion contractures at the MTPJs of the lesser digits, which is appreciable here. (photograph courtesy of Dr. Sarah M. Fitzgerald, DPM)

Considering the history, physical exam, and radiographs presented, how would you proceed with this case? Please reply with your thought and perspectives, and we will share them in a future RI.

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