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Vertical Talus



Vertical Talus
Typical appearance of a “rocker bottom foot.” Courtesy of Texas Children’s Hospital.

The talus bone is the small bone in the ankle that sits between the tibia and fibula of the lower leg (shin) and the calcaneus (heel bone).  The talus connects the lower leg to the foot, and it typically points towards the toes.   In a foot with vertical talus, the talus points towards the ground. 
With the talus positioned in the wrong direction, the bones that normally form in front of it now sit on top of the talus.   The front end of the talus points down towards the sole of the foot and the bones at the end of the foot bend back upward.  This results in a stiff foot with no arch that is frequently called a “rocker bottom foot”. 
Vertical talus can occur by itself or may be associated with other conditions such as arthrogryposis, spina bifida, or other neurologic conditions.  Because of these associations, your doctor may wish do to additional tests.
There is also a less severe form of this deformity called oblique talus. In children, with oblique talus, the talus bone is positioned in the wrong direction while weight bearing, but aligns normally when the foot is pointed down.  The foot appears to be more severe than the usual flatfoot, but less severe than a foot with vertical talus. 



Doctor Examination

Vertical talus is usually noted at birth; however, it can sometimes be detected on ultrasound during pregnancy.  Examination of the foot is important.  Your doctor will try to feel the bones in the foot and manipulate the foot to see if the deformity is flexible or rigid.  Some children will be walking age or even older and have one or both feet appear very flat when standing.
Your doctor will probably order an x-ray.  In particular, an x-ray with the foot pointing downward (referred to as plantarflexion) can help determine if the bones in front of the talus line up properly or are stuck on top of the talus. 

Vertical Talus Xray
Lateral foot X-ray of child with congenital vertical talus demonstrating that the 1st ray (big toe) cannot line up with the talus bone even when pushed down (plantar-flexed).

In oblique talus, the x-rays will show that the talus lines up with the toes when the foot is plantar flexed.
Vertical Talus Dorsiflextion
Lateral foot X-rays of child with oblique vertical talus demonstrating that the 1st ray (big toe, red line) does not line up with the talus bone (yellow line).
Vertical Talus Platarflexion
Lateral foot X-rays of an oblique vertical talus shoes that the 1st ray (big toes, red line) better lines up with the talus bone (yellow line) when the foot is pushed down (plantar-flexed).




Vertical talus should be treated with the goal of providing a painless, stable, functional foot that fits in shoes comfortably.  Initially, vertical talus is not painful.  If left untreated, however, the foot will remain deformed and eventually become painful as the child begins to walk and increase activity.  Calluses or skin breakdown can occur in the flattened arch area, making it difficult to wear shoes and walk.

Nonsurgical treatment

Some surgery is usually needed to correct the vertical talus deformity.   Before surgery, however, your doctor may recommend a trial of stretching or casting to improve the flexibility of the foot.   This may decrease the amount of surgery that is needed, or, in some cases, prevent the need for surgery all together.   Casting usually requires multiple visits to your doctor since casts need to be changed almost weekly for multiple weeks.  This serial casting technique allows the foot to stretch gradually without causing too much pressure in any one area at any one time. 

Surgical Treatment

If the foot doesn’t correct with non-surgical techniques, surgery will likely be recommended.  If some of the deformity improved with casting, the surgery may be limited to behind the ankle area alone.  If, however, the foot remains rigidly deformed, the surgery will be more extensive and typically done just prior to one year of age.
The goal of surgery is to correct the position of the bones within the foot.  This will likely require lengthening tendons or ligaments to allow the bones to be moved.  The bones are then held in place with pins and a cast.  The pins can usually be removed in the office in 4 to 6 weeks.  A special shoe or brace may be recommended to try to prevent recurrence of the deformity.  Your doctor will likely recommend follow up visits for a few years to see make sure the foot grows well and doesn’t need additional treatment.


More Information

Q: How is a vertical talus different from other flatfoot deformities?

In vertical talus, the talus points down and the other bones in the foot are stuck on top of it.  This is a rigid deformity.  A traditional flatfoot has well-formed bones and joints, but there is extra laxity or looseness that allows the arch to sag. 

Q: Do all cases of vertical talus require treatment?

Yes.  Without treatment, vertical talus results in abnormal weight bearing and pressure problems for the foot.  Shoe wear can be difficult, and callus or skin breakdown can occur.  Treatment often requires surgery to align the bones in the foot; however, casting may be tried to correct the deformity or decrease the amount of surgery that needs to be done.

Q: Why does a child develop vertical talus?

Nobody truly knows.  Vertical talus can occur as an isolated deformity, or it can be associated with conditions such as spina bifida, arthrogryposis, or other neurologic disorders.  Your doctor can determine if these conditions are present.

Q: If my child has vertical talus that will likely require surgery, why try casting?

Casting can help stretch the tendons and ligaments in the foot.  By changing the cast weekly over multiple visits, the foot may loosen up enough to either avoid surgery or limit the amount of surgery that needs to be done.  Less surgery decreases scarring and stiffness and may allow for better foot function.

Questions to ask your doctor:

  • How does vertical talus differ from other flatfeet?
  • Will my child need surgery?
  • Will my child need special shoes?
  • What will happen if we don’t treat the foot?
  • Will my child be allowed to play sports?