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Vertical Talus: Symptoms, Causes, and Treatment Options

Dr. Patrick DeHeer

Reviewed by
Dr. Patrick DeHeer

Vertical talus, also known as “rocker-bottom foot,” affects one out of every 10,000 newborns, and it affects both feet in about half of these cases.

Infants suffering from this condition have rigid, inflexible feet that turn outward, with a reversed arch that curves outward like the bottom of a rocking chair.

Symptoms of Vertical Talus to Look For

The appearance of rocker bottom results from a malformation of the talus bone in the ankle. The talus (pronounced tay-lus) normally serves as part of the system that connects the leg to the foot, and it helps to distribute weight evenly among the bones of the ankle.

In an infant with vertical talus, however, the bone has formed in the wrong position, causing the other bones that would normally be in front of it to shift position so that they lie on top of it instead (if this is difficult to visualize, see our article on the anatomy of ankle bones).

This causes the arch to curve in the wrong direction, so that the plantar region of the foot is lower than the toes and the heel. In especially severe cases, the toes may even touch the shinbone.

Because of its rarity, vertical talus is sometimes misdiagnosed as some other form of neonatal flatfoot, or even as clubfoot.

What Causes Vertical Talus?

Congenital vertical talus is idiopathic in most cases, meaning that the cause is unknown. It is believed to be genetic in origin, and is in some cases associated with chromosomal abnormalities.

On the other hand, many cases are associated with otherwise well-understood congenital neuromuscular diseases such as neurofibromatosis, arthrogryposis, or spinal bifida.

Some studies have suggested that abnormal positioning of the fetus in utero may cause this deformity. If your child is born with this condition, it is important to understand that it is not your fault; vertical talus is not preventable.

What Are The Complications of Vertical Talus?

Despite its appearance, this condition is is not painful for newborns, and even toddlers with uncorrected vertical talus can walk without much discomfort. If the condition remains untreated, however, the long-term consequences can be severe and disabling.

It is important for this condition to be treated as quickly as possible, before the deformity progresses. The ideal time for treatment is after six months but before the age of two.

If your child’s rocker-bottom foot is not treated before he or she begins to learn to walk, painful skin conditions such as calluses—and worse—will develop.

Eventually the foot will not be able to bear weight without pain, and the child will develop a severely abnormal gait (most likely walking on the inside of the foot), and will probably have difficulty balancing. Finding shoes to fit the deformed foot will be extremely difficult.

Once this has happened, painful and difficult physical therapy will be necessary in order for your child to walk normally, even after the problem has been corrected.

Surgical Treatment of Vertical Talus – What to Expect

Historically, vertical talus has been treated with surgery. The major reconstructive procedures employed to this end are accompanied by a host of potential complications, including surgical wound necrosis (tissue death leading to gangrene) and joint stiffness.

Often these procedures undercorrect the deformity, and further surgery is needed later.

Surgical correction involves realigning the bones into their correct positions and inserting pins to keep them in place.

Some ligaments and tendons may need to be surgically lengthened as well. (Some more drastic surgical procedures exist that even involve fusing the bones together to prevent recurrence.) Following surgery the child will have to wear a cast for four to six weeks, after which a brace may be necessary to prevent the foot from reassuming its improper position.

Non-surgical Treatment of Vertical Talus – What to Expect

The good news is that less painful and invasive treatment methods have been developed that may eventually make surgery unnecessary. Surgeons at St. Louis Children’s Hospital, led by Dr. Matthew Dobbs, are developing a modified version of the Ponseti method, a nonsurgical technique for correcting clubfoot.

This method, which is often used in conjunction with the surgery it may one day replace, involves stretching of the foot and ankle followed by the application of casts to hold it in place.

Once the correction is complete, the child undergoes a minimally invasive minor surgery in which a pin is inserted to keep the now properly aligned bones in place.

Following this procedure, a cast is placed on the foot and leg and left there for two weeks, after which it is replaced with a brace and a new cast. After another month, the cast and the pin are removed.

At this point a labor-intensive phase of the correction begins for the parents, who now bear the brunt of the responsibility for ensuring that their child’s rehabilitation holds up over time.

The child is now given a brace that must be worn for 23 hours each day for two months, and then for 14 hours a day over the next two years. The parents are also taught stretching exercises that must be performed on the child’s foot four times daily.

While this procedure is difficult, the advantage of it is that it obviates the need for numerous invasive and painful surgeries that might still not fully correct the problem, leading to arthritis and other problems farther down the road, possibly as soon as adolescence.

Talking to your Doctor

Here are some questions you can ask your doctor about vertical talus:

  • Do you recommend surgery for my child’s vertical talus, or is there some other option?
  • If you recommend the modified Ponseti method, what are my child’s chances for a complete recovery when the years of therapy are finally over with? What will be the consequences if I am insufficiently diligent about the stretching exercises?
  • If you recommend surgical correction, how soon do you think we should begin? Will there be other treatment prior to surgery?
  • Does my child suffer from any other related conditions?

Medical References:

    Gurnett CA, Keppel C, Bick J, Bowcock AM, Dobbs MB (September 2007). "Absence of HOXD10 mutations in idiopathic clubfoot and sporadic vertical talus". Clinical Orthopaedics and Related Research 462: 27–31. American Academy of Family Physicians http://www.aafp.org/afp/2004/0215/p865.html University of Maryland Medical Center http://umm.edu/programs/orthopaedics/services/pediatric/flat-feet St. Louis Children's Hospital http://www.stlouischildrens.org/our-services/center-foot-disorders/vertical-talus http://www.stlouischildrens.org/sites/default/files/services/foot_disorders/files/SLC6645%20Vertical%20Talus%20Insert%20web.pdf http://www.stlouischildrens.org/our-services/center-foot-disorders/ponseti-method-clubfoot/treatment American Academy of Orthopaedic Surgeons http://orthoinfo.aaos.org/topic.cfm?topic=A00612 National Center for Biotechnology Information http://www.ncbi.nlm.nih.gov/pubmed/18160500 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2656724/ American Orthopaedic Foot & Ankle Society http://www.aofas.org/footcaremd/overview/Pages/Glossary.aspx

This page was last updated on October 1st, 2015



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