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Hi All,

A couple of days ago i saw a case of bilateral peroneal spastic flat foot in a 13 year old boy. He was referred from ortho with a request for medial arch supports. Had x-rays, and the report states nothing osseus going on and no signs of coalition (xray attached (Left foot labelled)). Although I would like a second opinion... Does that Left foot show a bar like structure at the superior part of the calcaneo-cuboid joint?

He presented c/o pain on the dorsum of the foot over the styloid process which corresponded with the course of the peroneous brevis tendon and dorsal aspect of the met-cuboid joint, after extended periods of sitting at his computer (roughly 2x 2 hours per day). He doesn't do much activity or sport.

O/e he exhibits all the signs of peroneal spastic flat foot (rigid abducted, everted foot). General assessment shows global hypermobility (8/9 beighton score), with 90/60 degrees ext/int rotation of the hip and 20+ deg of hyper ext of knee.

When I was palpating along the course of the peroneal muscles on his right leg I felt the muscle spontaneously relax. Has anyone seen this happen?? This did allow me to examine the Rom in the right foot, which was hyper mobile with no obvious signs of a coalition. Trying to palpate trigger points in the left leg led to a little relaxation of the muscle but not completely. I feel that could be tied in with radiological findings?? Maybe I'm speculating a little too wildly..

Since I saw the patient I've read articles a couple of articles:

Lowy LJ: Pediatric Peroneal Spastic Flatfoot in the Absence of Coalition: A Suggested Protocol. JAPMA 88: 4, 1988

Diagnosis and Treatment of Pediatric Flatfoot: Harris et al. Jour. Foot and Ankle Surg. 43: 6, 2004

These both outline peroneal nerve blocks and walking casts as being good treatment modality for this condition.

Can anyone share their experiences with this condition, and do people think (in light of the spontaneous relaxation of the right leg) that this is manageable with just PT and Pod intervention. I can forsee that it may be challenging to convince the referring Ortho to carry out a peroneal nerve block.

Any advice would be very gratefully received!

Kindest Regards,

Sam

 

Have you ruled out Trevor disease? (dysplasia capital femoral epiphysis hemimelica)

A temporary peroneal nerve block can be used as a diagnostic tool in cases without coalition to acertain if it is purely muscular involvement. If you approach the Ortho this way, not initially looking for permanent blockage, then they should be more amenable to the idea.

Also look at adjusting the sitting position while on the computer.

Hope that helps.

 

His symptoms could be Iselins disease, but I would arrange MRI in case of a fibro-cartilaginous coalition, which is often the case and not picked up on X-ray.