In this section
Updated by: Allison Duey-Holtz
Updated on: August 2, 2017
An adduction or medial deviation of the forefoot that is recognized as a contracture at the tarsometatarsal joints
Signs and symptoms
- Deformity usually present at birth but may not present until the first year of life (3)
- Incidence estimated to be as high as 1 in 100 births (4)
- Spontaneous resolution to normal in 83%(1) to 95% (4) of cases by age one
- Pathogeneis is unknown but is believed to result from intrauterine crowding or positioning (4)
Referring provider's initial evaluation and management:
- Dynamic hallux varus
- Internal rotation of the foot
- Metatarsus primus varus
- Tibial torsion
- Radiographs- not needed unless child has failed casting
- Xerox of feet
Mild/moderate flexible approximately 7 months of age:
- No intervention passively correctible deformity will spontaneously correct on its own by age 1 (3,4)
- Educate families that the deformity should not interfere with normal development and that the child will have no restrictions or limitations in any sports or activities (4).
- Offer casting which works best in children under 8 months of age
Moderate/severe inflexible serial casting:
- Inflexible: Initiate treatment immediately
- If present at 8 months, may initiate serial casting as the percentage of favorable outcomes decreases if treatment was initiated after the patient was more than 8 months of age (1)
- If flexible, partially flexible at 8 months may cast
- Follow-up post casting to ensure no recurrence
When to initiate referral/ consider refer to Orthopedic Clinic:
Parental or provider concern.
What can referring provider send to Orthopedic Clinic?
1. Using Epic
- Please complete the external referral order
In order to help triage our patients and maximize the visit, the following information would be helpful include with your referral order:
- Urgency of the referral
- What is the key question you would like answered?
Note: Our office will call to schedule the appointment with the patient.
2. Not using Epic external referral order:
- In order to help triage our patients maximize the visit time, please fax the above information to (414) 607-5288
- It would also be helpful to include:
- Chief complaint, onset, frequency
- Recent progress notes
- Labs and imaging results
- Other Diagnoses
- Office notes with medications tried/failed in the past and any lab work that may have been obtained regarding this patient's problems.
Specialist's workup will likely include:
After referral to Orthopedic Clinic:
- Comprehensive birth history
- Family history
- Neuromuscular exam
- Gait evaluation
- Evaluate for hip dysplasia (9)
- Complete rotational profile (internal and external hip rotation, thigh-foot axis, transmalleolar axis, heel bisector angle, foot progression angle) (1,3,4)
- Neuromuscular exam
- Assessment of the foot, assess for degree of flexibility (4)
- Evaluate for hip dysplasia or other congenital orthopedic conditions(4)
- Evaluate heel bisector line (1)
- Identify: flexible, partially flexible, inflexible
If flexible & less than 7 months:
- f/u as needed at 7 months
- Bi-weekly for 6-8 weeks if treating with plaster casts (2)
Follow-up with surgeon:
- Over age 2years old
- Rigid/Inflexible after casting
- Operative treatment is not needed or desirable in patients who have mild or moderate deformities past age 2yo(3)
Evidence-based literature review
Bleck, E.E. (1983). Metatarsus adductus: Classification and relationship to outcomes of treatment. Journal of Pediatric Orthopedics. 3, 2-9.
Farsetti, P., Weinstein, S.L., & Ponseti, I.V. (1994). The long-term functional and radiographic outcomes of untreated and non-operatively treated metatarsus adductus. Journal of Bone & Joint Surgery. 76, 257-265.
Hart, E.S., Grottkau, B.E., Rebello, G.N., & Albright, M.B. (2005). The newborn foot: Diagnosis and management of common conditions. Orthopaedic Nursing. 24(5), 313-321.
Herring, J. A. (2008). Disorders of the foot. In M.O. Tachdjian & J.A. Herring (Eds), Tachdjian’s Pediatric Orthopedics (4th Ed) (pp.1035-1186). Philadelphia: Saunders Elsevier
Katz, K., David, R., & Soudry, M. (1999). Below-knee plaster cast for the treatment of metatarsus adductus. Journal of Pediatric Orthopedics. 19(1), 49-50.
Ponseti, I.V. & Becker, J.R. (1966). Congenial metatarsus adductus: The results of treatment. The Journal of Bone & Joint Surgery. 48, 702-711.