Flat foot

1. PresenterDr. Sushil Paudel

3. 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

4. ANKLE – plantarflexion and dorsiflexion
SUBTALAR (TALOCALCANEAL) – inversion and
eversion
MIDTARSAL – adduction and abduction, flexion and
extension, supination and pronation

5. 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

7. 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

8. 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

12. 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

13. Exact incidence not known
One of the most common orthopedic deformities
Affects 15 - 20% of adults, mostly asymptomatic
Of this 2/3
rd
have flexible flatfoot , 1/4
th
have a contracted tendo-
achilles associated with a flexible flatfoot and the remainder
have rigid flatfoot the most common cause being tarsal coalition

15. 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

16. An arched foot is a distinctive feature of man

A) Two longitudinal arches
◦Medial longitudinal arch
◦Lateral longitudinal arch
B) Transverse arch

17. 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

18. 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

20. 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

22. 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.

23. 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

24. FLEXIBLE
Depending on mobility of tarsal
joints
RIGID

25. PHYSIOLOGIC – due to ligamentous laxity in 1
st
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

26. 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

27. Congenital
Tarsal coalition
Congenital vertical
talus
Acquired

28. 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

29. 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)

30. No broad consensus
Unstable architecture of tarsal bones
Congenitally short tendo achilles
Weakened muscle power
Ligamentous laxity

31. 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

32. 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

33. 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

34. 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

36. Non weight bearing radiographs are essentially normal

37. 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

38. 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

39. 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 1\4
inch wedge on the inner border
Custom molded orthotics

42. 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

43. 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

45. 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

46. 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)

47. 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

48. 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

50. 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

52. TECHNIQUE
Elevation of tibialis posterior tendon
Elevation of osteoperiosteal flap from proximal to distal
Naviculocuneiform arthrodesis
Advancement of osteoperiosteal flap
Advancement of tibialis posterior

54. Displacement of the posterior half of the calcaneus
medially
Reestablishes the weight bearing line
Indicated in cases with excessive heel valgus

55. Koutsogiannis calcaneal osteotomy

56. 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

59. Nonunion of calcaneal graft
Displacement of the graft requiring revision
Diplacement of the calcaneocuboid joint
Recurrence of deformity or pain

60. Indicated for correction of residual deformities in flat foot
Forefoot supination is corrected by a plantar medial closing
wedge osteotomy of first cuneiform

62. Tarsal coalition (peroneal spastic flatfoot,
congenital rigid flatfoot) [most common cause]
Heel cord tightening
Accessory navicular
Vertical talus

63. Cannot be passively manipulated without causing
pain
Feet are flat - regardless of weight bearing / position
Pain is usually a prominent symptom.

64. 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

65. 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%

66. Talipes cavo varus
Talipes equino varus
Fibular hemimelia
PFFD
Neivergelt-pearlman syndrome- massive tarsal and carpal
coalitions
Apert’s syndrome-synostosis of tarsal bones

67. 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

70. 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

74. 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

75. 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

81. 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

82. 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%

84. 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.

85. 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

86. 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

87. 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

88. 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

89. 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

90. Kidner’s procedure

91. 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

93. 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

95. 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

97. 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 1/3
rd
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

98. Muscle imbalance
Intra-uterine compression
Arthrogryposis
Autosomal dominant transmission
Arrest of fetal development of the foot between 7
th
and 12
th

weeks of gestation

99.  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)

100. 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

101. Idiopathic flatfoot
Paralytic flatfoot
Spurious correction of clubfoot
Talipes calcaneovalgus (benign condition easily amenable to
correction)
Tarsal coalition

102. Calcaneus is held in eversion by contracted interosseous
ligament, bifurcated ligament and calcaneofibular ligament
Calcaneus is fixed in equinus by contracted posterior
capsule and achilles tendon
Dorsal capsules of talonavicular, calcaneocuboid joints and
tibio-navicular portion of the deltoid ligament are markedly
contracted and prevent reduction
Tibialis anterior, long toe extensors, peroneus brevis and
triceps surae are contracted
Posterior tibial and peroneal tendons may be displaced
anteriorly so that they act as dorsiflexors rather than plantar
flexors

104. Forefoot dorsiflexors are contracted
Calcaneonavicular ligament is elongated and attenuated
Posterior tibial tendon becomes attenuated as it passes over the
displaced head of talus
If deformity persists into late childhood, alterations in the bony
shape develop that encourage redisplacement even after
surgery
Talus assumes hour-glass constriction, calcaneus becomes
curved dorsally at its anterior end becoming beak shaped and
navicular becomes wedge shaped

105. Difficult to treat tends to recur
Manipulation and cast application are rarely successful
and if reducible by closed means a diagnosis of oblique
talus is made
But manipulation and serial casting keeps the skin and
soft tissues stretched
Open reduction is generally required

106. 1 - 4 years : soft tissue release and open reduction
(KUMAR, COWELL, RAMSEY)
4 - 8 years : soft tissue release and open reduction with
Grice-Green subtalar extra-articular arthrodesis
>12 years, failure of above procedures : triple
arthrodesis
Children > 3 yrs with severe deformity generally require
navicular excision at the time of open reduction

107. Should be done before 2 yrs
Best done as a single stage release at 1 yr
STEPS
Dorso-lateral soft tissue release
Medial soft tissue release
Reduction of talonavicular and calcaneocuboid jts
Posterior soft tissue release
Internal fixation

112. Results are satisfactory if surgery is done before 27
months
All feet have some residual midfoot sag and forefoot
abduction and some have decreased motion
Commonest reason for surgical failure is inadequate
reduction of the navicular

113. Aseptic necrosis of the navicular
Aseptic necrosis of the talus
These can be averted by limited amount of dissection

115. Most common cause of adult onset acquired flat foot
TREATMENT
NSAIDS
Intrasynovial injection of corticosteroids
Splintage with outside iron and inside T strap

117. Unilateral deformity that develops rapidly
History of trauma
Young patient- tendon transfer using flexor digitorum longus
Elderly- splintage
If this fails and symptoms are marked triple arthrodesis