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Subtalar Joint Morphology and the Determinants of Flexible Flatfeet in Children

Discussion in 'Biomechanics, Sports and Foot orthoses' started by NewsBot, Mar 25, 2015.

  1. NewsBot

    NewsBot The Admin that posts the news.


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    Subtalar Joint Morphology and the Determinants of Flexible Flatfeet in Children
    Alpesh Kothari, MD, MSc, Oxford, United Kingdom
    Julie Stebbins, PhD, Oxford, United Kingdom
    Amy B. Zavatsky, PhD, Oxford, United Kingdom
    Tim Theologis, Oxford/ Oxfordshire, United Kingdom
    Presented at AAOS Annual Meeting; March 2015
  2. Jeff Root

    Jeff Root Well-Known Member

    Is the lack of an anterior facet the chicken or the egg? I suspect these children always had a flat foot with an adducted and plantarflexed talus (i.e. a wide talocalcaneo angle) and as a result, never developed (the need for) an anterior facet at the STJ because there was no articulation occurring between the head of the talus and the calcaneus in this area. Why did the authors of this study presume
    rather than consider the possibility that this osseous relationship (foot morphology) always existed and as a result, the soft tissue and spring ligament were always elongated because of the nature of the osseous relationship or structure of the foot?

    If we could identify these children, and if we could use an orthosis to adduct the head of the talus by reducing STJ pronation, then it is possible that they might develop a more supportive anterior facet and a less flat foot as an adult. This study could possibly be used to help justify orthotic intervention in pediatric flatfoot, especially if there is a family history of adult flatfoot in the child's parent or parents.

  3. Seamus McNally

    Seamus McNally Active Member

    I'm trying to imagine how Wolff's Law might apply here.
    - If left to nature will the bone morphology adapt?
    - Does the use of orthosis enhance a better architecture of the bone over time?
    - or could the use of orthosis prevent the development of beneficial bone adaptation?
    My personal feeling is that I would be delighted if such studies could help nail the paediatric treat -or-not-to- treat dilemma for once and for all
  4. ran tao

    ran tao Welcome New Poster

    Hi there
    If you google "foot binding", you can find a counterexample how external force changes the morphology of the foot.
  5. Jeff Root

    Jeff Root Well-Known Member

    Here are some pictures of a foot skeleton I have that doesn't have an anterior facet. It is an extremely flat foot that demonstrates no calcaneal inclination angle. The calcaneus has a large spur that extends over the dorsal aspect of the cuboid, presumably to create stability. The trochlea of the talus is adducted and the neck and head are abducted. In spite of the abducted position of the head and neck, the head of the talus does not articulate with the calcaneus (see view of plantar surface). This is a good example of what can happen when there is no anterior calcaneal facet.


    Attached Files:

  6. Jeff Root

    Jeff Root Well-Known Member

  7. Yes
    Unknown- define orthosis, for starters.
  8. Jeff, these are dry bones held together by cat-gut or wire: how can you possibly glean that it is "an extremely flat foot", let alone know the calcaneal inclination angle?

    I agree with your "chicken and egg", BTW.
  9. Jeff Root

    Jeff Root Well-Known Member


    One can tell a lot about structure and function from osseous members. Anthropologists look at bones and draw conclusions about how extinct creatures functioned. To answer your question, I will post some photos to help explain how I drew my conclusions.

    Here are photos of two foot skeletons. When you place the joint surfaces together the foot in question has no lateral longitudinal arch as compared to a more normal foot, which clearly demonstrates a lateral arch in the sagittal plane. Also, the foot in question demonstrates a large beak that overrides the cuboid. This blocks dorsiflexion of the cuboid. If I try to create a lateral arch, there is a gap at the dorsal aspect of the CC joint. This would not occur during weightbearing activity.

    In addition, as I mentioned in one of my previous posts on this thread, there is significant evidence in the structure of the talus to suggest that this was an extemely pronated and flat foot.


    Attached Files:

  10. And we all know how basing a sample on n=1 precarious and then extrapolating is potentially dangerous. Here's an exmple relating to fossil's: http://www.unmuseum.org/dinobront.htm

    Jeff, with the greatest respect, the bones you have are wired together, there are no soft tissues and no neural system. Really...? If you rotate the skeleton of the "extemely flat foot" around about the medial tubercle of the calc, so that the trochlear surface is more horizontal, what does it become?

    All we see here is human variation in the shape of dry bones which have been wired together by people who had no idea of their relationships with one another in-vivo. Viva variation, though.
  11. Jeff Root

    Jeff Root Well-Known Member


    I'm just expressing my observations and opinion. You have every right to disagree if you like.

  12. Like I said, I agree with your "chicken and egg", I just have difficulty in drawing opinions about measurements which normally are made in-vivo, such as calcaneal inclination angle, based upon wired-up dry bones on a bench.
  13. STfootcare

    STfootcare Member

    Great article but I'd like to read the whole thing. Not published yet?

    Question for the "Wolff's law" theorists...If stress could cause such severe bone remodeling that the calcaneus distorts to a position where the anterior facet does not articulate with the talus, how come only SOME kids develop flatfoot.

    So, if the effect of Wolff's law is equal in everyone, that is, the same law applies to every child, wouldn't we see a trend of flatfeet occurring in overactive toddlers/children? The late walkers would have higher arches? Generally, all kids are"flat footed" as toddlers.

    Does anyone know of any reference of Wolff's law affecting normal bone growth? I've never heard of it described as a factor in bone maturity. Not sure it applies here...
  14. efuller

    efuller MVP

    Rather than what the paper claimed to show. We might be able to conclude foot shape (arch height) from the articulations. When the transverse plane talo calcaneal angle is so high that the talar head does not articulate with the facet, then we are probably looking a flat foot. That is the correlation that the paper showed. However, the authors made the assumption that the absence of the anterior facet made the foot less supportive. I think the three of us are in agreement that the talar head was adducted relative to the calcaneus and there was no mechanical stimulus for the anterior facet to develop.

    As an aside, an interesting finding in Jeff's picture of the foot bones without the anterior facet, is the amount of calcaneus that goes over the top of the cuboid. That overhang, as opposed to a flat surface could increase the stiffness of the midtarsal joint.

  15. efuller

    efuller MVP

    The theory is that not every foot starts in the same position. Some feet will have a higher transverse plane talo calcaneal angle at birth and those are the ones who never develop an anterior facet.

  16. STfootcare

    STfootcare Member

    So you're saying that articulating facets, (basically joint spaces - right?) develop in response to stimuli?
    I don't have any real knowledge on cell differentiation but I figured that as the calcaneus develops, those calcaneal tissues are programmed to grow into the calcaneus, and any real anomalies are the product of genetic differences, DNA programming.
    The idea that anatomical bone shape could be determined or changed by pressure or stimulus is new to me. If you have any reference or source for more info on this, I'm interested.
  17. The development of the "ball and socket ankle" is a nice example of bone adaptation:
  18. STfootcare

    STfootcare Member

    Simon Spooner, thank you for the article!
    They state that 7 of the ankle joints studied had normal shape at birth and remodeled by the age of five. (From what I read there weren't newborn x-rays available for the others.)
  19. efuller

    efuller MVP

    In addition to Simon's example there is the example of a pseudo arthhrosis that occurs when there is continued motion at a fracture site.

    Another example is serial casting for club foot. The adult x-rays of people casted have more normal looking joint facets than those that were not treated.

    There was an old paper by Salter (of the pediatric growth plate injury classification system) where he drilled holes in rabbits knees. There were 3 recovery regimens: in a cast, walking around a cage, continuous passive motion machine. The cartilage was examined after a period of time. The quality of the cartilage was much better with continuous passive motion, ok with walking around the cage and worst when in a cast. So the mechanical input had an effect on the wound healing. There is no reason to think that the mechanism is different in development. It's been a few years since I read about wound healing. It is a fascinating subject.

  20. I found this to be a useful refresher on bone remodelling: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2919071/
  21. Ball and socket ankle- pictures attached- this guy was a competitive triathlete. It's probably best to think of bone morphology in terms of phenotype (geometric shape) = genotype + environment + (genotype x environment).

    Attached Files:


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