Congenital Vertical Talus

Congenital vertical talus is a rare congenital foot deformity in which the sole of a child’s foot flexes abnormally in a convex position giving the foot a rocker-bottom appearance. For this reason, this condition is often called rocker-bottom foot.

When a child is born, their feet usually appear flat because of the extra fat pads on the bottom. As the child grows, a concave arch in their foot normally develops. In a child with rocker-bottom foot, the bottom of the foot flexes in the opposite direction, making the middle of the foot touch the floor, while the toes and heel curve upward, touching the shin.

Rocker-bottom foot affects about 1 in 10,000 births and occurs equally in boys and girls. In about half of the cases, both feet are affected.

Congenital vertical talus is usually a rigid deformity, unlike the more common calcaneovalgus foot (flexible deformity), and rarely improves with stretching or bracing. In most cases, surgery is required.

Congenital vertical talus is often associated with an underlying musculoskeletal or neurological condition such as:

• Spina bifida
• Trisomy 13, 14, 15 or 18
• Arthrogryposis multiplex congenita

In a minority of cases, the cause of rocker-bottom foot is unknown, in an otherwise healthy child.

The most common symptom of congenital vertical talus is a rocker-bottom appearance of the foot, which is usually obvious at birth or seen when a child begins to walk.

Other symptoms include:

• An upward flex of the mid- and forefoot
• The hindfoot is elevated due to an abnormal flex in the ankle
• The midfoot cannot be properly aligned with the hindfoot
• Abnormal positioning of the foot; child may walk on the inside of their foot, while the outside edge is elevated, leading to improper balance and weight distribution

Early detection of congenital vertical talus is important for successful treatment. At Children's Hospital of Philadelphia (CHOP), a trained pediatric orthopaedic physician will perform a complete medical history, a physical examination and a visual evaluation of your child.

During the physical exam, the doctor will examine your entire child — not just their foot. The doctor will be looking for other abnormalities such as multiple joint contractures or evidence suggesting your child may have a larger multisystem genetic disorder.

Doctors will also closely examine your child’s foot — while standing and in motion — to determine if your child has rocker-bottom foot, or a more common and benign conditions such as calcaneovalgus foot or flat foot. Though symptoms of these conditions may mimic each other in young children, treatments are very different.

To confirm the diagnosis or better understand the anatomy of your child’s foot and leg, doctors may also order imaging tests such as:

• X-rays, which produce images of bones. The hallmark of this deformity is an abnormally positioned talus bone (this is the bone that connects the foot to the ankle).
• EOS imaging, an imaging technology that creates 3-dimensional models from two flat images. Unlike a CT scan, EOS images are taken while the child is in an upright or standing position, enabling improved diagnosis due to weight-bearing positioning.
• Computed tomography (CT) scan, which uses a combination of X-rays and computer technology to examine bones and produces cross-sectional images ("slices") of the body.
• Magnetic resonance imaging (MRI), which uses a combination of large magnets, radiofrequencies and a computer to produce detailed images of organs, soft tissues, muscles, ligaments and other structures within the body. Your child is exposed to no radiation during an MRI.

If your child appears to have a neurological condition, the orthopedic physician may refer your child to a neurologist for a complete neurological exam.

All children with congenital vertical talus will require some form of treatment. While some children may be helped with non-surgical treatment, most will require surgery.

Doctors may recommend a variety of non-surgical treatments to prevent your child’s condition from getting worse. These include:

• Stretching exercises for the forefoot and hindfoot
• Serial manipulation and casting of the midfoot and forefoot in a flexed position to reduce the upward curve of the foot

Improvements from these treatments do occur, but are often temporary.

Surgery for congenital vertical talus is complicated because it involves correcting foot movement in three directions — side-to-side, up-and-down and front-and-back. A specialist in pediatric foot deformities should perform it.

With adequate serial casting, need for extensive soft-tissue release surgery can be minimized to minimally invasive tendon procedures which leave smaller scars and shorter recovery time. Other procedures can include bone work in older children.  

Surgery can dramatically improve the long-term outcomes for your child with congenital vertical talus, but it can also be a stressful experience for you and your child.

At CHOP, we offer a wealth of resources that can help you and your child prepare for surgery. Additionally, we follow many best practices before, during and after surgery to decrease the risk of infection and increase positive outcomes. Our safety protocols have been so successful that many other institutions have adopted them.

To learn more, read how we make safety in surgery a top priority.

At Children's Hospital of Philadelphia, we offer a wealth of ongoing support and services for your child and family at our Main Campus and throughout our CHOP Care Network. Our team is committed to partnering with you to provide the most current, comprehensive and specialized care possible for your child.

We recognize your child's pediatrician as an important part of the clinical team and provide regular updates on your child's progress. If continued care and monitoring is necessary long-term, we will help transition your child's care to an adult orthopedic team.

Most children who are surgically treated for congenital vertical talus have good outcomes. Some children may need an orthotic to ensure proper foot alignment during critical growth and development periods.

Children who have rocker-bottom feet as part of a larger neurological or musculoskeletal syndrome will likely need lifelong follow-up care.