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Flat foot

This document discusses flat feet (pes planus), including its anatomy, causes, types, symptoms, physical exam findings, and treatment options. Key points include: - Pes planus is characterized by a low or absent medial longitudinal arch. It can be flexible or rigid. - Causes include ligament laxity, obesity, muscle weakness, bony abnormalities, and tarsal coalitions. - Treatment focuses on orthotics, stretches, braces, and surgery if conservative options fail. Surgical procedures include tendon lengthening, osteotomies, and fusions.

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Presenter Dr. Sushil Paudel
 Also known as pes planus  Medial border of the foot is abnormally in contact with the floor during weight bearing  Low or absent medial longitudinal arch  When associated with deformities of the hind, mid and fore foot – pes plano valgus
 ANKLE – plantarflexion and dorsiflexion  SUBTALAR (TALOCALCANEAL) – inversion and eversion  MIDTARSAL – adduction and abduction, flexion and extension, supination and pronation
 Forefoot - abduction and supination (relative to hind foot)  Talar head - displaced medially, anteriorly and downwards  Calcaneum everts, dorsiflexes - hindfoot is in valgus  Navicular- subluxates dorso-laterally, uncovering the talar head  The medial column of the foot appears to be longer than the lateral column
 Navicular, cuneiform, cuboid become wedge- shaped, with apex directed dorso-laterally  Plantar, spring and deltoid ligaments are stretched  Anterior, posterior tibial tendons and plantar muscles are stretched whereas the achilles tendon and peronei become adaptively shortened  Calluses develop over the medial bony prominences
 Meary’s angle - between long axis of talus and long axis of first metatarsal on a standing lateral Xray 0 degrees – normal 0 – 15 degrees – mild 15 – 30 degrees – moderate > 30 degrees – severe  The location of the sag, talo-navicular, naviculo-cuneiform or both can also be determined
 Calcaneal pitch - angle between the plantar surface of the calcaneum and horizontal on a lateral x-ray  Normal 15 degrees , in flat foot is decreased  May be 0 or negative in case of tightened TA  The talocalcaneal angle on an AP view is a marker of hind foot valgus  Talus much more vertical than normal
 Exact incidence not known  One of the most common orthopedic deformities  Affects 15 - 20% of adults, mostly asymptomatic  Of this 2/3rd have flexible flatfoot , 1/4th have a contracted tendo- achilles associated with a flexible flatfoot and the remainder have rigid flatfoot the most common cause being tarsal coalition
 The medial longitudinal arch normally develops during the first decade of life  Therefore flatfeet are usual in infants, common in children and rare in adults FOOTNOTE - Flatfoot in an infant is actually a ‘fat foot’ as the excessive amount of fat obscures the arches
An arched foot is a distinctive feature of man A) Two longitudinal arches ◦ Medial longitudinal arch ◦ Lateral longitudinal arch B) Transverse arch
 Supports body weight in upright posture  Acts as a lever to propel the body forwards in walking, running and jumping  Acts as a shock absorber  Concavity of the arches protects the soft tissues of the sole against pressure
Ends : Anterior : 1-3 MT heads Posterior : Medial tubercle of calcaneum Summit: Superior articular surface of body of talus Pillars : Anterior: Talus, navicular, 3 cuneiforms, 1-3 MT Posterior: Medial half of calcaneum
 Shape of bones: wedge shaped with apex pointing downwards. The talus acts as a key-stone  Intersegmental ties: ligaments and muscles Spring ligament Dorsal ligaments - interosseus talocalcaneal ligament Tendinous extensions of tibialis posterior
 Tie beams or bow strings : connect two ends of an arch Medial part of plantar aponeurosis Medial part of the flexor digitorum brevis Abductor hallucis, flexor hallucis longus, flexor hallucis brevis Medial part of flexor digitorum longus.
Slings : suspend the arch from above Tibialis posterior, Flexor digitorum longus, Tibialis anterior and peroneus longus Flexor hallucis longus - bulkiest and strongest muscles supporting med arch
FLEXIBLE Depending on mobility of tarsal joints RIGID
 PHYSIOLOGIC – due to ligamentous laxity in 1st decade  HYPERMOBILE FLATFOOT – excessive ligamentous laxity – familial, Down’s, Marfan’s, Ehlers-Danlos, Osteogenesis Imperfecta  BONY ABNORMALITIES – hypoplasia of sustentaculum tali, hypoplastic calcaneum  OCCUPATIONAL  OBESITY
 MOTOR WEAKNESS – posterior tibial tendon dysfunction, accessory navicular, muscular dystrophy, peripheral nerve lesions, cerebral palsy, spinal cord conditions like polio, myelodysplasia, Werdnig – Hoffman disease, spina- bifida  SECONDARY TO ANATOMIC DEFECTS ELSEWHERE : Ext. rotation of the limb Genu valgum Equinus deformity of the ankle (tight tendo- achilles) Varus deformity of the foot
Congenital Tarsal coalition Congenital vertical talus Acquired
 Inflammatory arthrosis, Traumatic arthrosis  Charcot foot  Residua of clubfoot  Contractures of peronei or TA - Rheumatoid arthritis, Gout, Degenerative arthritis, Infection, Acute sprain, Osteochondral fracture, Foot tumors especially osteoid osteoma
Hereditary condition Marked ligamentous laxity Deformity disappears when feet are freed of weight bearing Weight bearing axis - shifted medial to normal position Prolonged weight bearing in the everted foot - Heel cord contractures ( flexible flatfoot associated with tight heel cord)
 No broad consensus  Unstable architecture of tarsal bones  Congenitally short tendo achilles  Weakened muscle power  Ligamentous laxity
 Age of presentation: adolescence  Usually bilateral and asymptomatic  Family history of flatfeet and joint hyper mobility  Pain, discomfort, burning sensations and fatigue on activity and prolonged standing, cramping at night  Felt around the navicular, talocalcaneal joint, below the medial malleolus or at the ant. or post. extremities of the plantar ligaments
 Flatfoot only on weight bearing  Deformity correctable on passive manipulation by placing the foot in equinus and inverting the heel  Deformity correctable on tip toe standing  Deformity correctable by voluntarily contracting the tibialis and long toe flexors  Jack’s (great toe extension) test - the arch can be restored by simply dorsiflexing the great toe – suggests that sag is at the naviculocuneiform level
 Examine the tendo-achilles for tightness (TA contracture tends makeS flexible flatfoot symptomatic)  Short tendo-achilles: limited dorsiflexion(not able to walk on heels)  Harris and Beath documented that presence or absence of the longitudinal arch did not corelate with the disability and a flatfoot was compatible with normal function unless associated with a tight tendo- achilles  Examine ROM of ankle,subtalar, midtarsal joints  Examine the gait  Generalized ligamentous laxity  Hypermobility of the subtalar and mid-tarsal joints: the forefoot can be bent outwards and upwards to an unusual degree
 Spine, hips and knees should be examined  General examination for neuromuscular abnormalities  Don’t forget to examine the shoes shoes show excessive wear along the medial border Pedobarography  A record of pressures can be obtained by making the patient to stand and walk on a force plate. Mainly used to compare pre and post operative function
Non weight bearing radiographs are essentially normal
 Physiological flexible flatfoot with full ROM is asymptomatic  It does not cause pain or disability  Xrays are not indicated and treatment is not required  Child should be left alone  If symptomatic always look for associated causes most commonly tight heel cord
Mainstay of treatment as  This is what is required in majority  Condition is essentially benign  Only symptomatic treatment possible  No change in ultimate shape of the foot FOOTNOTE – it is the parents and grand parents who need treatment and not the child
Conservative treatment should always be tried first  Arch supports, rubber inserts, Plastizote  Whitman valgus brace  UCBL (University of California Biomechanics Laboratory) heel inserts  Shoe modifications –Thomas heel or a 14 inch wedge on the inner border  Custom molded orthotics
 Do not alter underlying structural fault  Do not encourage redevelopment of the arch  Running sports shoes have been found to be as effective as traditional orthoses and are more socially acceptable FOOTNOTE - They reduce shoe wear and are said to be more effective in treating shoes rather than feet
 Toe-walking and multiple toe-ups  If tendo-achilles is contracted, stretching it actively and passively is an important form of management  Grasping marbles with toes Heel to toe walking  Playing in sand  Ballet dancing  Walking on a supination board FOOTNOTE - There is no scientific study evaluating the effectiveness (or lack of it) of these exercises
 Reserved for patients with intractable symptoms unresponsive to shoe or orthotic modifications and who are unable to modify pain producing activity  Limitation of daily activities is an indication for surgery FOOTNOTE - Surgery for flexible flatfoot should not be performed for cosmetic reasons
 Soft tissue procedures – achilles tendon lengthening  Arthroeresis of the subtalar joint  Osteotomy - lateral collumn lengthening (DILLWYN EVANS, PHILIPS, MOSCA, ANDERSON AND FOWLER), posterior calcaneal osteotomy (GLEICH, KOUTSOGIANNIS), transverse calcaneal osteotomy to raise the floor of the sinus-tarsi (CHAMBERS, MILLER), osteotomies of medial cuneiform and cuboid  Arthrodesis – limited medial collumn arthrodesis (HOKE, DURHAM, CALDWELL, COLEMAN), subtalar arthrodesis (these procedure should be condemned as subtalar motion is lost and arthritic changes invariably develop in the other tarsal joints), triple arthrodesis (indicated as a salvage procedure when other procedures have failed)
 Arthrodesing procedures should be delayed until 10 and preferably 15 years  Before 10 years arthrodesis is difficult because of excessive cartilaginous component of tarsal bones  Subsequent bony growth is retarded  Patient must be prepared to accept permanent loss of inversion-eversion motion
Achilles tendon lengthening is included if the ankle lacks at least 10 degrees of dorsiflexion with the knee extended If patient has severe enough symptoms to warrant surgery, then heel cord lengthening should be part of a comprehensive procedure to reconstruct the arch TECHNIQUE  3 small insicions( 2 medial, 1 lateral) along the length of the tendon  Tendon is cut from midline outwards  Tendon sheath is repaired to prevent scarring  Closure is done with knee extended and ankle dorsiflexed  Long leg cast with ankle in neutral is given for 6 weeks
 A silicone or silastic implant (Smith –STA peg) is placed into the sub talar joint  The plantar flexed posture of the talus and valgus at the subtalar joint is limited by the interposition peg  Generally performed in young children  Potential complications (such as synovitis, peroneal spastic flatfoot, stiffness of the sub talar joint and foreign body reaction) are many  95% success has been claimed but this procedure requires further investigation
TECHNIQUE  Elevation of tibialis posterior tendon  Elevation of osteoperiosteal flap from proximal to distal  Naviculocuneiform arthrodesis  Advancement of osteoperiosteal flap  Advancement of tibialis posterior
 Displacement of the posterior half of the calcaneus medially  Reestablishes the weight bearing line  Indicated in cases with excessive heel valgus
Koutsogiannis calcaneal osteotomy
 Osteotomy is fashioned in a coronal plane 1.5 cm posterior to the calcaneocuboid joint between the anterior and middle facets  This is not a simple opening wedge osteotomy, but rather a lengthening distraction wedge osteotomy, and it requires a trapezoid graft  Tricortical iliac crest graft is inserted between the anterior and middle facets of the calcaneus  Additional internal fixation is required
 Nonunion of calcaneal graft  Displacement of the graft requiring revision  Diplacement of the calcaneocuboid joint  Recurrence of deformity or pain
 Indicated for correction of residual deformities in flat foot  Forefoot supination is corrected by a plantar medial closing wedge osteotomy of first cuneiform
 Tarsal coalition (peroneal spastic flatfoot, congenital rigid flatfoot) [most common cause]  Heel cord tightening  Accessory navicular  Vertical talus
 Cannot be passively manipulated without causing pain  Feet are flat - regardless of weight bearing / position  Pain is usually a prominent symptom.
 Thin or thick bar composed of bone (synostosis), cartilage (synchondrosis) or fibrous tissue (syndesmosis) connects tarsal bones  Failure of embryonic segmentation  Calcaneum is held in eversion  An irritative focus is produced which causes painful spasm of the peronei  Impossible for the patient to walk on the lateral border of the foot due to limited inversion  Mechanics of the tarsus is impaired and abnormal stresses result casing sec. degenerative arthritis
 Symptoms : do not develop until ossification of the fibrous syndesmosis or the cartilagious synchondrosis  Syndesmosis and synchondrosis are usually more troublesome than synostosis  Symptoms – vague foot pain, difficulty in walking on uneven surfaces, foot fatigue, painful limp  Tenderness is present along the bar  The condition is known to run in families  Auto. dominant inheritance with variable penetrance  50% bilateral  Incidence - 0.4-6%
 Talipes cavo varus  Talipes equino varus  Fibular hemimelia  PFFD  Neivergelt-pearlman syndrome- massive tarsal and carpal coalitions  Apert’s syndrome-synostosis of tarsal bones
 Symptomatic at 8 – 12 yrs  Varying loss of subtalar motion  Best seen on a 45 degree lat oblique projection  Beaking of dorsal articular margin of talus is uncommon  CT is usually not required
 Middle facet talocalcaneal coalition is most common  Symptomatic at 12 – 16 yrs of age  Marked reduction or absence of subtalar motion  Best seen on a Harris view – posterosuperior oblique projection  Talar beaking is commonly seen – traction spur and not a sign of degenerative arthritis  CT is usually needed for diagnosis
Most patients respond to conservative treatment –  Rest  Shoe inserts (arch supports)  Orthotics (AFO, Plastizote, UCBL insert)  Shoe modifications (high top shoes, Thomas heel, Whitman plate)  4-6 weeks of immobilization in a short leg walking cast with the foot plantigrade may provide lasting relief of symptoms  Splintage with an outside iron and inside T-strap
 Resection of the bar and interposition of muscle, fat or gelfoam – should be performed before secondary degenerative changes have set in  Calcaneal osteotomy can be combined to to correct hind foot valgus  Subtalar arthrodesis  Triple arthrodesis
 Extensive talocalcaneal coalition  Multiple coalition  Development of sec. degenerative arthritis  Ball and socket ankle joint  When the coalition involves more than 50% articular surface of talocalcaneal joint or more than 50% of the posterior facet
 First described by Bauhin in 1605  Also called prehallux, accessory scaphoid, os tibiale externum, os naviculare secondarium and navicular secundum  Separate ossification center for the tuberosity of the navicular  Prevalance 5-10%
Cause and effect relationship with flatfoot has not been shown 3 types  Round sesamoid bone within TP tendon - rarely symptomatic  8-12 mm ossicle connected to the navicular by a synchondrosis. This is the type that is usually symptomatic as the synchondrosis is at risk of disruption from traction injury / shear forces Navicular beak / Cornuate navicular -fusion of acc. navicular with the primary navicular.
 Usually asymptomatic, noticed incidentally  Presentation - adolescence  Pain over an enlarged area at the medial aspect of the navicular just at the insertion of the tibialis posterior tendon  Pain aggravated by wearing tight-fitting shoes
 Accessory navicular is best seen on the external oblique view  Accessory navicular ossifies even later than a normal navicular which is the last tarsal bone to ossify  CT can identify an accessory navicular  Bone scan can identify a hot accessory navicular
 Soft pads, avoid wearing tight fitting shoes  Special shoes, valgus correcting shoe inserts( UCBL devise)  Steroid and analgesic injections  Strenghening of tibialis tendon and treatment of tendonitis  Immobilization in a short leg cast
 Simple excision of the accessory navicular shelling it out of the post. tibial tendon  Navicular is resected until it is slightly depressed relative to the talus and cuneiform  Bone wax is applied to the to prevent regrowth Good or excellent result in 93% cases
 Involves excision of the accessory navicular with re-routing of the central slip of the tibialis posterior laterally onto the plantar surface of the navicular, where it is sutured under tension to the surrounding ligaments  Gives no added advantage in short term and long term follow up and therefore the simpler procedure is preferred
Kidner’s procedure
 Congenital rigid flat foot, rocker bottom foot, convex pes valgus or teratologic dorsolateral dislocation of the talo-naviculo-cuneiform joint  First description by Henken in 1914  Characteristic features described by Lamy and Weissman
 Congenital dislocation of talonavicular joint such that the talus is disposed vertically with its head forming the most prominent part of the sole  The navicular is displaced dorsolaterally firmly lodged on to the neck of the talus, preventing reduction. The navicular abuts the ant. surface of the tibia  The calcaneum is displaced posterolaterally in relation to the talus, is rigidly locked into equinus and in contact with the distal fibula  The angle between the long axis of the talus and calcaneum is markedly increased  The forefoot is deviated outwards and dorsally and hence the sole has a convex contour
 Dorsolateral dislocation or extreme subluxation of calcaneocuboid joint might occur  Abnormal relationship of tarsal bones remain constant whether the foot is plantar flexed or dorsiflexed, this is in contrast to congenital flexible flatfoot  Achilles tendon is contracted, ant. tibial and peroneal tendons are taught  The subtalar joint is abnormal with the anterior facet absent and the middle facet hypoplastic
 Adaptive changes occur in the tarsal bones with weight bearing  The talus becomes shaped like an hour glass, with its longitudinal axis almost same as the tibia  Only the posterior 1/3rd of the superior articulating surface of the tibia articulates with the tibia  Anterior part of the plantar surface of the calcaneus becomes rounded  Callosities develop beneath the anterior end of the calcaneus and along the medial border of the foot superficial to the head of the talus
 Muscle imbalance  Intra-uterine compression  Arthrogryposis  Autosomal dominant transmission  Arrest of fetal development of the foot between 7th and 12th weeks of gestation
 Spina bifida  AMC  Trisomy of Ch-13, 14, 15, 18  Microcephaly  Prune belly syndrome  Spinal muscular atrophy  Neurofibromatosis  Congenital dislocation of hip  CNS abnormality can produce this deformity by muscle imbalance( weak posterior tibial and strong peroneals)
 Usually bilateral  Sole is characteristically convex at birth, so that it resembles the bottom of a rocking chair and hence the name  Dorsolateral fold is deep and situated at the mid-tarsal area  Talar head is prominent over the medial and plantar aspects  Deformity from the outset is rigid  Deformity may be so severe that heel might not touch the ground at all  Gait is awkward and resembles a waddle  Shoes are rapidly worn out over the inner sides  Pain - at adolescence or soon thereafter