flat foot.ppt [pes planus ] #physio.# rehabilitation

its pes plano valgus . flat foot is a loss of medial arch of foot . flat foot is common conditions.

1. PES PLANUS  Dr. Priyanka 

2. PES PLANUS/PES PLANOVALGUS /FLAT FOOT 

3. Classification  Two types : Arch of height  Heel eversion angle 

4. Arch height  medial longitudinal arch structure was found to be a ratio of navicular height to foot length .

5. Heel eversion angle  Heel eversion or hindfoot valgus Child foot posture and calcaneal eversion to reduce degree every 12  month to vertical position by 7 years . A vertical heel is optimal for foot function . Foot angle for children from 6 to 16 years  is 4 degree   

6. Foot structure type  

7. Flexible flat foot  The longitudinal arches of foot are present on heel elevation and non- bearing but disapper with full weight bearing on the foot 

8. Rigid flat foot   The longitudinal arch of foot are absent in both heel elevation and weight bearing 

9. causes Congenital pes planus  General hypermobility  Cerebral palsy  Subtalar joint morphology  Acquired pes planus  Diabetes Rupture of posterior tibial tendon Arthritis, muscular dystrophy Traumatic injury  Posterior  tibial tendon transfer 

10. Other condition of congenital pes planus   Peroneal spasm  Congenital Vertical talus  CTEV Ligament laxity  Down syndrome and marfan syndrome

11. Pathophysiology   The arch fails to develop result if tightness in calf muscles ,laxity in the achilles tendon or poor core stability in other areas around of hips 

12. Dynamic factors  Soft tissue factors: 1.Insufficency of posterior tibial tendon  2.Peroneal spastic flat foot  3.Muscle weakness by poor posture  Neurology factors: 1.Myelination of the pyramidal fibers to the foot is incomplete at birth .

13. STATIC FACTORS  Bony architecture of the medial longitudinal arch . Fixed or rigid pes planus is due to structural abnormality.

14. Clinical presentation   History : In adult frequent ankle rolling /ankle sprains  Children presenting with pes planus asymptomatic  Pain (mid foot ,heel, lower leg, knee, hip,  back ) Observation : Foot may flat or rocker bottom In standing –calcaneal valgus and foot eversion  Gait : walking on heel  Viewed from posteriorly looking for the 'too many toes sign ' Look at running or walking shoes uneven distribution of body weight with resultant one sided wear of shoes leading to further injuries 

15. Palpation : Contracted achilles tendon may show limitation of dorsiflexion  Test subtalar and transverse tarsal motion  Subtalar motion :  stabilises ankle with one hand , calcaneus  other hand. The calcaneus is then inverted and everted .Normal range of motion is between 20 degree and 60 degree. Inversion being 2x the ROM of eversion  Tarsal motion : grasp the calcaneus is one hand and forefoot in other . The normal adduction of forefoot is about 30 degree ,abduction about 15 degree 

16. Diagnosis :

17. Supination resistance test

18. Jacks test and feiss angle Hallux is manually dorsiflexed while child is standing  If medial longitudinal arch rise due to dorsiflexion of hallux the foot is considered flexible flat foot  If medial longitudinal arch unchanged the considered rigid flat foot  Purpose this test to check the flexibility of foot  Feiss line is the line interconnecting malleolus medialis ,navicular, and first metatarsal head  The inclination of this line with ground increases when the first metatarsophalangeal joint is dorsiflexed ( jack test ) Dorsiflexion activates forefoot supination and rises  the arch height ( 140degree plus and minus 6 degree )

19. Ankle range 

20. Management  Flexible pes planus : Foot orthoses produces improvement in children with pes planus  The child should be fitted with flat lace up shoe with a firm heel and MLA , a broad and deep toe box and the ' toe break' at the junction between the anterior third and posterior two third of the shoe .  In children 10 years old , flexible flat foot is considered permanent ,therefore long term orthotics can be used to prevent secondary problems 

21. Management  Rigid flat foot: Surgery is required  Tendon transfer , osteotomies , arthrodesis  Others surgery fails then , triple arthrodesis is performed 

22. PHYSIOTHERAPY MANAGEMENT 

23. Pain management 

24. Exercises  Walking bear foot  Flexibility exercises are passive ROM exercises of all ankle and all foot joints  Stretching of gastrocnemius soleus complex and peroneus brevis muscles to facilitate varus and foot adduction  Heel cord stretch for the achilles tendon and calf muscles to relief tight heel cord 

25. Strengthening  Strengthening exercises are given to anterior and posterior tibialis muscle and the flexor hallucis longus , intrinsic, interosseus plantaris muscles and abductor hallucis to prevent valgus and flattening of anterior arch . Arch muscle strengthening exercises with theraband  Global activation of the muscles known to support the medial longitudinal arch and the varus with and without resistance  Single leg weight bearing  Toe walking 

26. Proprioception