Natural History of Foot Deformities in Children with Cerebral Palsy

  • Freeman MillerEmail author
  • Chris Church
Living reference work entry


Foot deformities in children with cerebral palsy may result from the interaction of many factors, including muscle spasticity and imbalance, soft-tissue contractures, bony torsion, and joint instability, all of which occur, for the very young child, within a dynamic context of neurologic maturation and longitudinal growth. Such a complicated scenario makes it difficult to describe the natural history of foot deformity in children with CP. In order to determine the most effective treatment paradigms and critically evaluate their outcomes, such knowledge is essential. Gait maturation in typically developing children occurs from the onset of walking through age 7 years, during which time, the movement, forces, muscle activity, and temporal parameters of gait evolve through predictable patterns of change. The natural history of gait maturation of children with CP does not follow these typical patterns, especially as related to timing. The young child with CP who starts to walk usually has planovalgus feet and equinus. The natural evolution of this deformity is for the foot to improve with less planovalgus and improved heel contact as the child goes through early childhood. Children with better neurologic function, meaning they are able to walk independently, will have a higher degree of improvement in the foot position towards normal and will continue to improve later, up to age 7 years. Some children at age 2 may have very severe planovalgus deformities that will have completely corrected by age 7 years and even on occasion will over correct into equinovarus. This means that there should seldom be surgery to correct planovalgus foot deformities prior to age 7 and only then for the most severe deformities. It is important to allow the foot to make its maximum natural correction by utilizing therapy and orthotics on a part-time basis. Data to support this approach are presented in this chapter.


Cerebral palsy Natural history Planovalgus Equinus Orthotics Arthroereisis 


  1. Abel MF, Juhl GA, Vaughan CL, Damiano DL (1998) Gait assessment of fixed ankle-foot orthoses in children with spastic diplegia. Arch Phys Med Rehabil 79:126–133CrossRefPubMedGoogle Scholar
  2. Andreacchio A, Orellana CA, Miller F, Bowen TR (2000) Lateral column lengthening as treatment for planovalgus foot deformity in ambulatory children with spastic cerebral palsy. J Pediatr Orthop 20:501–505PubMedGoogle Scholar
  3. Bell KJ, Ounpuu S, DeLuca PA, Romness MJ (2002) Natural progression of gait in children with cerebral palsy. J Pediatr Orthop 22:677–682PubMedGoogle Scholar
  4. Bosch K, Rosenbaum D (2010) Gait symmetry improves in childhood – a 4-year follow-up of foot loading data. Gait Posture 32:464–468CrossRefPubMedGoogle Scholar
  5. Carlson WE, Vaughan CL, Damiano DL, Abel MF (1997) Orthotic management of gait in spastic diplegia. Am J Phys Med Rehabil 76:219–225CrossRefPubMedGoogle Scholar
  6. Chang CH, Miller F, Schuyler J (2002) Dynamic pedobarograph in evaluation of varus and valgus foot deformities. J Pediatr Orthop 22:813–818PubMedGoogle Scholar
  7. Church C, Lennon N, Alton R, Schwartz J, Niiler T, Henley J, Miller F (2017) Longitudinal change in foot posture in children with cerebral palsy. J Child Orthop 11:229–236CrossRefPubMedPubMedCentralGoogle Scholar
  8. Crawford AH, Kucharzyk D, Roy DR, Bilbo J (1990) Subtalar stabilization of the planovalgus foot by staple arthroereisis in young children who have neuromuscular problems. J Bone Joint Surg Am 72:840–845CrossRefPubMedGoogle Scholar
  9. Davids JR (2010) The foot and ankle in cerebral palsy. Orthop Clin N Am 41:579–593CrossRefGoogle Scholar
  10. de Coulon G, Turcot K, Canavese F, Dayer R, Kaelin A, Ceroni D (2011) Talonavicular arthrodesis for the treatment of neurological flat foot deformity in pediatric patients: clinical and radiographic evaluation of 29 feet. J Pediatr Orthop 31:557–563CrossRefPubMedGoogle Scholar
  11. de Moraes Barros Fucs PM, Svartman C, de Assumpcao RM, Yamada HH, Simis SD (2012) Surgical technique: medial column arthrodesis in rigid spastic planovalgus feet. Clin Orthop Relat Res 470:1334–1343CrossRefPubMedGoogle Scholar
  12. Figueiredo EM, Ferreira GB, Maia Moreira RC, Kirkwood RN, Fetters L (2008) Efficacy of ankle-foot orthoses on gait of children with cerebral palsy: systematic review of literature. Pediatr Phys Ther 20:207–223CrossRefPubMedGoogle Scholar
  13. Hanna SE, Rosenbaum PL, Bartlett DJ, Palisano RJ, Walter SD, Avery L, Russell DJ (2009) Stability and decline in gross motor function among children and youth with cerebral palsy aged 2 to 21 years. Dev Med Child Neurol 51:295–302CrossRefPubMedGoogle Scholar
  14. Harryman SE (1992) Lower-extremity surgery for children with cerebral palsy: physical therapy management. Phys Ther 72:16–24CrossRefPubMedGoogle Scholar
  15. Heydemann JA, Abousamra O, Franzone JM, Kaufman BE, Sees JP (2018) What's new in the management of foot deformities in children with cerebral palsy. J Pediatr Orthop 38:e20–e24CrossRefPubMedGoogle Scholar
  16. Karol LA (2004) Surgical management of the lower extremity in ambulatory children with cerebral palsy. J Am Acad Orthop Surg 12:196–203CrossRefPubMedGoogle Scholar
  17. McKeon PO, Hertel J, Bramble D, Davis I (2015) The foot core system: a new paradigm for understanding intrinsic foot muscle function. Br J Sports Med 49:290CrossRefPubMedGoogle Scholar
  18. Molayem I, Persiani P, Marcovici LL, Rosi S, Calistri A, Villani C (2009) Complications following correction of the planovalgus foot in cerebral palsy by arthroereisis. Acta Orthop Belg 75:374–379PubMedGoogle Scholar
  19. Renshaw TS, Green NE, Griffin PP, Root L (1996) Cerebral palsy: orthopaedic management. Instr Course Lect 45:475–490PubMedGoogle Scholar
  20. Sees JP, Miller F (2013) Overview of foot deformity management in children with cerebral palsy. J Child Orthop 7:373–377CrossRefPubMedPubMedCentralGoogle Scholar
  21. Sobera M, Siedlecka B, Syczewska M (2011) Posture control development in children aged 2–7 years old, based on the changes of repeatability of the stability indices. Neurosci Lett 491:13–17CrossRefPubMedGoogle Scholar
  22. Sutherland DH, Davids JR (1993) Common gait abnormalities of the knee in cerebral palsy. Clin Orthop Relat Res 288:139–147Google Scholar
  23. Sutherland DH, Olshen R, Cooper L, Woo SL (1980) The development of mature gait. J Bone Joint Surg Am 62:336–353CrossRefPubMedGoogle Scholar
  24. Vedantam R, Capelli AM, Schoenecker PL (1998) Subtalar arthroereisis for the correction of planovalgus foot in children with neuromuscular disorders. J Pediatr Orthop 18:294–298PubMedGoogle Scholar
  25. Wren TA, Rethlefsen S, Kay RM (2005) Prevalence of specific gait abnormalities in children with cerebral palsy: influence of cerebral palsy subtype, age, and previous surgery. J Pediatr Orthop 25:79–83PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Nemours Alfred I. duPont Hospital for ChildrenWilmingtonUSA

Section editors and affiliations

  • Freeman Miller
    • 1
  1. 1.AI DuPont Hospital for ChildrenWilmingtonUSA

Personalised recommendations