Raising Questions On 'Planal Dominance' Article

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     I quickly scanned the article, “What You Should Know About Planal Dominance And Pronated Feet” (see page 52 in the June issue). I find it hard to believe there is no mention of forefoot supinatus as the key radiographic finding for the frontal plane component of flexible flatfoot. There is a mention of a positive Helbing’s sign. In my opinion, basing your treatment on the presence of a positive Helbing’s sign is irresponsible.

— Matthew DeMore III,
DPM, FACFAS
Assistant Professor
Chairman, Department of Surgery
Ohio College of Podiatric Medicine

Dr. Harris responds: I appreciate Dr. DeMore taking the time to comment on my article. The purpose of this article is to reacquaint readers with the concept of pronation as a multifaceted structural deformity and not a single clinical entity.

     In regard to Dr. DeMore’s points, let me take the issue of forefoot supinatus first. When the term forefoot supinatus was first introduced, it was used to describe an orthopedic lesion that was somewhere between a “rectus” forefoot and a rigid forefoot varus. In other words, they were describing flexible forefoot varus. The use of the term has evolved to describe radiographic features of this anatomical lesion as well. Unfortunately, the use of some of these terms is geographic. I do not use that term to describe radiographic findings. I reserve it for the clinical examination finding.

     Secondly, the term Helbing's sign is used to describe lateral deviation of the tendo-Achilles associated with an everted calcaneus. This term is ingrained in the literature and is unlikely to go away anytime soon. One could say the same thing about forefoot supinatus, resting calcaneal stance position, rectus and other terms that are popular in the biomechanical literature today. Refinement of this knowledge over time will probably lead to the introduction of new terminology, new meaning for old terms and probably abandonment of some of these terms.

     I used the term Helbing’s sign once in the article. It was used descriptively and not as a treatment determiner. I strongly disagree with Dr. DeMoore’s contention that the article infers that Helbing’s sign is used to determine treatment. It is used to further support the single clinical finding of an everted heel.

     I believe that most cases of forefoot supinatus and forefoot varus involve not only frontal or coronal plane malalignment of the forefoot against the rearfoot, but also some degree of sagittal failure of all or part of the medial column as well. The concept of sagittal failure of the medial column was well discussed and illustrated in case examples.

     The main thrust of this article is to identify those components of pediatric flatfoot that help determine therapeutic decision making. Not every pronated foot should be treated with orthoses. Not every pronated foot is a candidate for arthroereisis. Not every pronated foot is a candidate for lateral column lengthening or transverse shifting of the calcaneus. Treatment must be tailored to the deformity.

     An additional intent of the article is to remind the readers that equinus, primary ankle valgus and the position of the tibia with respect to the ground are also important (and very often overlooked) considerations in determining treatment.

— Edwin Harris,
DPM, FACFAS
Clinical Associate Professor
Department of Orthopaedics
And Rehabilitation
Loyola Medical Center
Maywood, Ill.