Congenital Vertical Talus

Congenital Vertical Talus (CVT) is a rare congenital deformity of the foot that results in a rigid flatfoot with a characteristic “rocker-bottom” appearance. The condition is caused by abnormal positioning of the talus and navicular bones in the newborn’s foot. The talus tilts vertically, and the navicular bone is dislocated dorsally, creating a fixed deformity that affects both the structure and function of the foot.

How Common It Is and Who Gets It? (Epidemiology)

Congenital vertical talus is extremely rare, with an estimated incidence of 1 in 150,000 live births. It occurs twice as often in males as in females and is bilateral in about half of all cases. The condition is frequently associated with other neuromuscular or chromosomal disorders, making early and thorough evaluation critical for proper management.

Why It Happens – Causes (Etiology and Pathophysiology)

The exact cause of CVT is unknown, but it is commonly linked to neuromuscular and developmental abnormalities that interfere with fetal foot positioning. Common associations include arthrogryposis, myelomeningocele, spina bifida, cerebral palsy, and congenital hip dislocation.
Pathologically, the deformity involves a vertical talus with dorsal dislocation of the navicular bone, calcaneal eversion, and soft tissue contractures. The peroneal and posterior tibial tendons are displaced, functioning as dorsiflexors instead of plantar flexors, further exacerbating the deformity. The Achilles tendon and peroneal muscles are usually tight, contributing to the rigid equinovalgus posture of the foot.

How the Body Part Normally Works? (Relevant Anatomy)

The talus bone forms the connection between the leg and the foot, transferring weight from the tibia to the foot through the ankle joint. The navicular sits in front of the talus and supports the medial arch. In normal alignment, these bones articulate smoothly to allow proper motion of the foot and ankle. In CVT, the navicular shifts dorsally, and the talus becomes vertically oriented, disrupting the normal arch and producing the rigid, convex plantar surface characteristic of the deformity.

What You Might Feel – Symptoms (Clinical Presentation)

Newborns or infants with CVT present with a rigid, non-correctable flatfoot deformity. The hindfoot points downward (equinus) while the forefoot is dorsiflexed and abducted, producing the “rocker-bottom” shape. The talar head may be prominent and palpable on the sole of the foot. Deep creases may appear on the top of the foot. As the child begins to walk, pain and calluses may develop under the talar head, and walking can become awkward, often described as a “peg-leg gait.”

How Doctors Find the Problem? (Diagnosis and Imaging)

Diagnosis is primarily clinical, confirmed by imaging studies.
Radiographs, including anteroposterior (AP), oblique, and lateral foot views, show a vertically positioned talus with dorsal dislocation of the navicular. On lateral views, the line drawn through the talus passes below the first metatarsal axis instead of intersecting it.
A forced plantar flexion lateral radiograph is diagnostic, showing a persistent dorsal dislocation of the talonavicular joint even when the foot is forced downward. The Meary’s angle (formed by the talus and first metatarsal) exceeds 20°. MRI or spinal imaging may be ordered to evaluate for associated neurologic disorders.

Classification

Congenital vertical talus may be classified based on cause or flexibility:

• Idiopathic CVT – isolated deformity without associated disorders.

• Neuromuscular CVT – associated with systemic conditions such as spina bifida or arthrogryposis.

• Syndromic CVT – associated with chromosomal abnormalities.
  The deformity can also be described by rigidity, ranging from flexible to rigid, though true CVT is typically fixed and stiff at birth.

Other Problems That Can Feel Similar (Differential Diagnosis)

Conditions that may mimic CVT include:

• Oblique talus: A milder, reducible deformity where the talonavicular subluxation corrects with plantar flexion.

• Calcaneovalgus foot: A benign, flexible deformity that resolves with stretching.

• Posteromedial tibial bowing: Causes an apparent foot deformity due to bone curvature.

• Tarsal coalition: Causes stiffness and flatfoot in older children.

Treatment Options

Non-Surgical Care
Initial management focuses on serial manipulation and casting to stretch contracted soft tissues and partially correct the deformity. The foot is gently manipulated into inversion and plantarflexion and held in position with a cast, which is changed weekly.
Casting typically improves flexibility but rarely achieves complete correction, so surgical intervention is almost always required.

Surgical Care
Surgery is the mainstay of treatment for congenital vertical talus and is usually performed between 6 and 12 months of age. The procedure involves surgical release of tight structures, reduction of the dislocated talonavicular joint, and stabilization with pins. The spring ligament is reconstructed, and the Achilles, peroneal, and extensor tendons are lengthened as needed.
A minimally invasive approach similar to the Ponseti technique used for clubfoot correction may be used in selected cases. This involves serial casting followed by closed reduction and percutaneous Achilles tenotomy once correction is achieved.
In severe or resistant cases, a talectomy (removal of the talus) or triple arthrodesis (fusion of the subtalar, talonavicular, and calcaneocuboid joints) may be necessary as a salvage procedure in older children.

Recovery and What to Expect After Treatment

After surgical correction, the foot is immobilized in a cast for 4–6 weeks to maintain alignment. Once the cast is removed, physical therapy and bracing help maintain correction and strengthen the foot. Children generally recover well, achieving a stable, plantigrade foot suitable for normal walking. Long-term follow-up is required to monitor for recurrence.

Possible Risks or Side Effects (Complications)

Possible complications include overcorrection or undercorrection of the deformity, stiffness, infection, or wound healing problems. Delayed diagnosis or inadequate correction may lead to persistent deformity, gait abnormalities, or the need for further surgery.

Long-Term Outlook (Prognosis)

The prognosis for congenital vertical talus is good with early detection and appropriate treatment. Most children achieve a functional, pain-free foot. Untreated CVT, however, leads to severe disability, chronic pain, and deformity. Outcomes are less predictable when treatment is delayed beyond age three or when underlying neurologic disease is present.

Out-of-Pocket Costs

Medicare

CPT Code 28585 – Open Treatment of Talotarsal Joint Dislocation (e.g., Talonavicular Reduction with Fixation): $209.10

CPT Code 27685 – Lengthening or Shortening of Tendon, Leg, Single (e.g., Achilles or Peroneal Tendon Lengthening): $151.57

CPT Code 28715 – Triple Arthrodesis, Any Method (Fusion of Subtalar, Talonavicular, and Calcaneocuboid Joints): $221.63

CPT Code 27640 – Talectomy (Excision of Talus): $194.86

Medicare Part B typically covers 80% of the approved cost for these surgical procedures once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield generally cover that remaining 20%, reducing or eliminating out-of-pocket expenses for Medicare-approved surgeries. These plans coordinate with Medicare to fill the coverage gap and minimize patient responsibility.

If you have Secondary Insurance, such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it serves as a secondary payer. These plans typically cover any remaining balance, including coinsurance or small deductibles, which usually range from $100 to $300, depending on your plan and network.

Workers’ Compensation

If your congenital vertical talus correction is related to a work injury or aggravated by work-related activities, Workers’ Compensation will cover all medical expenses, including surgery, rehabilitation, and postoperative care. You will have no out-of-pocket expenses, as the employer’s insurance carrier directly pays for all approved procedures.

No-Fault Insurance

If your foot deformity or resulting treatment is connected to an automobile accident, No-Fault Insurance will typically cover the full cost of surgery and follow-up care. The only potential out-of-pocket cost may be a small deductible or co-payment based on your insurance policy.

Example

Liam Parker was diagnosed with congenital vertical talus requiring open talotarsal reduction (CPT 28585) and Achilles tendon lengthening (CPT 27685). His estimated Medicare out-of-pocket cost was $209.10. Since Liam had supplemental coverage through AARP Medigap, his remaining balance was fully covered, leaving him with no out-of-pocket expenses for the procedures.

Frequently Asked Questions (FAQ)

Q: What causes congenital vertical talus?
A: It is caused by abnormal positioning of the talus and navicular bones during development, often associated with neuromuscular or chromosomal disorders.

Q: How is it diagnosed?
A: Through clinical exam and X-rays showing a vertical talus and dislocated navicular.

Q: Can it be treated without surgery?
A: Casting can improve flexibility but surgery is usually needed for complete correction.

Q: What age is best for surgery?
A: Between 6 and 12 months, when the bones are still flexible and easier to correct.

Q: What happens if left untreated?
A: The deformity becomes rigid, painful, and severely limits walking.

Summary and Takeaway

Congenital vertical talus is a rare but serious foot deformity that causes a rigid, rocker-bottom foot due to dislocation of the talonavicular joint. Early diagnosis with imaging and prompt treatment are essential to achieve a functional, pain-free outcome. Most cases require both serial casting and surgery during infancy. Left untreated, the deformity becomes more rigid and disabling over time.

Clinical Insight & Recent Findings

A 2024 letter published in The Journal of Maternal-Fetal & Neonatal Medicine emphasizes the ongoing challenges of differentiating congenital vertical talus (CVT) from oblique talus before birth. While both deformities can appear similar on prenatal imaging, they differ significantly in rigidity and postnatal management.

In CVT, the talonavicular joint remains unreduced even when the foot is placed in plantar flexion, making it a fixed deformity. In contrast, oblique talus shows partial reduction, indicating flexibility. The authors caution that current ultrasound techniques cannot reliably distinguish between these two conditions in the womb due to the lack of ossification of the navicular bone before nine months of age.

They recommend postnatal confirmation by a pediatric orthopedist to avoid misdiagnosis and unnecessary parental distress or invasive procedures. This reinforces the importance of expert evaluation and careful imaging after birth for accurate treatment planning (“Study discussing prenatal challenges in diagnosing vertical versus oblique talus – see PubMed.“)

Who Performs This Treatment? (Specialists and Team Involved)

Treatment is provided by pediatric orthopedic surgeons specializing in foot and ankle deformities. A multidisciplinary team including neurologists, physiotherapists, and orthotists assists in diagnosis, postoperative care, and rehabilitation.

When to See a Specialist?

Parents should seek an orthopedic consultation immediately if an infant’s foot appears rigid, with the forefoot pointing upward and the sole convex, or if walking appears abnormal.

When to Go to the Emergency Room?

Emergency care is rarely required unless the foot shows signs of infection, redness, or severe swelling after surgery or casting.

What Recovery Really Looks Like?

Recovery involves several weeks of immobilization followed by bracing and therapy. Children typically begin walking normally once correction is achieved and maintained.

What Happens If You Ignore It?

Untreated congenital vertical talus leads to progressive stiffness, chronic pain, and deformity, often requiring extensive reconstructive surgery or fusion later in life.

How to Prevent It?

There is no known prevention since the condition develops in utero. However, early detection through newborn screening allows for effective treatment before rigidity sets in.

Nutrition and Bone or Joint Health

A balanced diet rich in calcium, vitamin D, and protein supports bone growth and healing after surgery or casting. Maintaining adequate nutrition helps improve recovery outcomes.

Activity and Lifestyle Modifications

After treatment, children can usually participate in normal activities with minimal restriction. Proper footwear and regular follow-up visits are recommended to ensure long-term stability and prevent recurrence.

Do you have more questions?