Pes planus

flat foot deformity

1. PES PLANUS PRESENTER DR. Ramkrishna dahal MS Resident TUTH

2. OVERVIEW…. Anatomy of arches of foot Definition and causations of pes planus Special discussions on more common causes: Flexible flat foot Congenital vertical talus Tarsal coalition Accessory navicular Posterior tibial tendon disorder Summary ..

3. ANATOMY OF ARCHES OF FOOT.. The springboards and shock absorbers of foot. There are three main arches of foot : medial longitudinal arch lateral longitudinal arch t ransverse arch The medial longitudinal arch needs special mention in discussing the aetiopathogenesis of pes planus Clinically Oriented Anatomy Moore , Keith L.; Dalley , Arthur F .

4. BONES OF MLA.. Calcaneum , talus , navicular, three cuneiforms and first three metatarsals

5. SUPPORTS OF MLA.. Describing the arch supports includes basically 4 headings:

6. For MLA support: The key stone is the TALUS The staples are PLANTAR LIGAMENTS, TENDON OF TIBIALIS POSTERIOR The tie beam is made by PLANTAR APONEUROSIS, FLEXOR DIG. BREVIS, ABDUCTOR HALLUCIS, FLEXOR HALLUCIS LONGUS, FLEXOR DIG. LONGUS, FLEXOR HALLUCIS BREVIS The suspension arch is made by TIBIALIS ANTERIOR, TIBIALIS POSTERIOR AND MEDIAL LIGAMENTS OF ANKLE JOINT

7. WHAT IS PES PLANUS?? A manifestation of various conditions in which the medial arch of the foot is diminished or absent, allowing the entire sole to touch the ground . May present as an asymptomatic incidental finding on examination or as a symptomatic condition Symptoms range from mild pain or restricted range of motion to severe disabling pain

8. ON PHYSICAL EXAMINATION.. Medial arch of the foot is depressed (REPRODUCIBLE/NON REPRODUCIBLE) Heel bone, when viewed from the rear is everted or in valgus Forefoot is abducted relative to the hindfoot “too many toes sign” REST FINDINGS ARE DISCUSSED IN SPECIFIC TOPICS…

9. INCIDENCE.. A depressed longitudinal arch occurs in approximately 23 % of the adult population. Of this population, approximately two thirds have a flexible, hypermobile flatfoot with normal or increased mobility of the subtalar complex and ankle joint. Approximately one fourth of flatfeet exhibit a contracture of the triceps surae associated with an otherwise typical hypermobile flatfoot, and this form of flatfoot is a known cause of disability in army recruits. The remainder of flatfeet are characterized by more rigidity of the subtalar joint, typically seen with tarsal coalitions. Tachdjian’sPediatricOrthopaedics,5 th edition

10. WHAT COULD BE THE CAUSES??

11. CONGENITAL FLAT FOOT ACQUIRED FLAT FOOT PES PLANOVALGUS ADULT FLEXIBLE FLATFOOT CONGENITAL VERTICAL TALUS TARSAL COALITION TENDON DYSFUNCTION-PTT,OR PERONEAL TENDONS POSTTRAUMATIC IATROGENIC ARTHRITIC CHARCOT FOOT OR NEUROMUSCULAR FLATFOOT

12. “…usual in infants, common in children, and within the normal range in adults..” Staheli and colleagues Exact incidence of flatfoot in children is unknown PES PLANOVALGUS Tachdjian’sPediatricOrthopaedics,5 th edition

13. Arch is usually obscured in an infant’s foot because of subcutaneous fat. Longitudinal arch develops during the first decade of life. The lateral talus–first metatarsal angle demonstrates a decrease in the amount of plantar sag of the midfoot until 8 years old. Tachdjian’sPediatricOrthopaedics,5 th edition

14. Painless most of the times. On examination: Inspection: excessive eversion during weight bearing, the forefoot is usually abducted, producing a midfoot sag with lowering of the longitudinal arch forefoot is actually supinated in relation to the hindfoo t medial column of the foot appears longer than the lateral column Palpation: talar head and navicular tuberosity appear to be in contact with the floor CLINICAL FEATURES.. Tachdjian’sPediatricOrthopaedics,5 th edition

15. Movement : may have increased mobility of ankle or subtalar joint Tests : Tip toe test : Inversion of the heels and arch reconstitution during toe standing

16. IS RADIOGRAPHY NECESSARY?? NOT NECESSARILY… BUT ONE CAN VISUALISE FOLLOWING PARAMETERS WITH ITS AID: lateral talus–first metatarsal angle, or Meary angle location of the sag— talonavicular or naviculocuneiform joint degree of plantar flexion of the talus most compelling reason to rule out causes of the deformity other than idiopathy

17. TREATMENT OF PES PLANOVALGUS.. Conservative Treatment In a typical case of a hypermobile (postural) flatfoot, no treatment is indicated in an asymptomatic pediatric patient. Education and reassurance are the mainstays. If an Achilles tendon contracture is present- stretching exercises TP strengthening exercises Tachdjian’sPediatricOrthopaedics,5 th edition

18. Is there any role of orthoses?? There is no scientific evidence that orthoses and medial arch supports are efficacious. BUT…in cases of medial arch pain and fatigue, as well as cramping at night the orthoses may be helpful. Wenger DR, Mauldin D, Speck G, et al: Corrective shoes and inserts as treatment for flexible flatfoot in infants and children, J Bone Joint Surg Am 71:800, 1989.

19. Surgical treatment: Indications: Intractable symptoms unresponsive to shoe or orthotic modifications In individuals who are unable to modify the activities that produce pain Surgical options include: ARTHROEREISIS- limits the amount of valgus motion in the subtalar joint by using an interposition peg HEEL CORD LENGTHENING SUBTALAR FUSION - only as salvage procedure . LATERAL COLUMN LENGTHENING IMBRICATION OF TALONAVICULOCUNEIFORM COMPLEX CALCANEAL OSTEOTOMY TRIPPLE ARTHRODESIS Tachdjian’sPediatricOrthopaedics,5 th edition

20. Lateral column lengthening Talonaviculocuneiform imbrication Tachdjian’sPediatricOrthopaedics,5 th edition

21. CONGENITAL VERTICAL TALUS A condition characterized by a fixed dorsal dislocation of the talonavicular joint in conjunction with rigid hindfoot equinus Aka congenital convex pes valgus, teratologic dorsolateral dislocation of the talocalcaneonavicular joint A cause of rigid pes planus 1 in 10000 live births Mann’s Surgery Of The Foot And Ankle Ninth Edition

22. ETIOLOGY AND ASSOCIATIONS.. Etiology is not yet known Autosomal dominant pattern of inheritance has been linked(12-20 % of idiopathic cases) Gene mutations (HOXD10 ) Associations: associated congenital anomalies are found in approximately 60% of patients in 10% of patients with myelomeningocele in 11% of patients with arthrogryposis trisomy 13,15 and 18 spinal muscular atrophy, neurofibromatosis, congenital dislocation of the hip Kumar SJ, Guille JT, Lee MS, et al: Osseous and non-osseous coalition of the middle facet of the talocalcaneal joint, J BoneJoint Surg Am 74:529, 1992. Tachdjian’sPediatricOrthopaedics,5 th edition

23. PATHOANATOMY BONY CHANGES : TALUS: hourglass shape , equinus position longitudinal axis is almost the same as that of the tibia, and only the posterior one third of its superior articular surface articulates with the tibia. NAVICULAR: articulates with the dorsal aspect of the neck of the talus and is locked there proximal articular surface is tilted plantarward CALCANEUM: displaced posterolaterally in relation to the talus in contact with the distal end of the fibula tilted into equinus

24. LIGAMENTOUS CHANGES: CONTRACTED ONES: tibionavicular portion of the superficial deltoid, bifurcated ligament, calcaneofibular ligament, and the interosseous talocalcaneal ligaments ATTENUATED ONES: spring ligament TENDONS AND MUSCLE CHANGES: CONTRACTURES OF : tibialis anterior, long toe extensors, peroneus brevis, and triceps surae PATHOANATOMY Posterior tibial and peroneal tendons may be displaced anteriorly so that they act as dorsiflexors rather than plantar flexors.

25. CLINICALLY.. ON INSPECTION: a rocker bottom foot, the apex of which is at the talar head deep creases dorsolaterally and below LM, callosities may be seen hindfoot foot is everted into a valgus, externally rotated position forefoot is abducted and dorsiflexed ON PALPATION: calcaneus is fixed in equinus , with a contracted achilles tendon peroneal and anterior tibialis tendons are taut navicular is palpable as it lies on the talar neck ON MOVEMENT: passive correction of deformity is impossible

26. IMAGING… X RAY: LATERAL PROJECTION: FORCED DORSIFLEXION LATERAL VIEW : FORCED PLANTAR FLEXION LATERAL VIEW: Tachdjian’sPediatricOrthopaedics,5 th edition

27. NORMAL FOOT CVT FOOT Tachdjian’sPediatricOrthopaedics,5 th edition

28. TREATMENT PRINCIPLES.. GOAL: To restore the normal anatomic relationships between the talus, the navicular, and the calcaneus to provide a normal weight distribution through the foot EARLIER BELIEF : Major reconstructive surgery was necessary to correct the deformities in the majority of patients though frought with substantial complications . RECENT BELIEF : Serial casting to stretch the contracted dorsal and lateral soft tissues and gradually reduce the talonavicular joint followed by later minimally invasive procedures for final correction. Mann’s Surgery Of The Foot And Ankle Ninth Edition

29. PRINCIPLES OF CASTING: forefoot is first stretched into plantar flexion and inversion by applying distal traction to the metatarsals upward push on the calcaneus and a downward pull on the heel may stretch equinus deformity Tachdjian has performed blind pinning of the talonavicular joint to maintain reduction while gradually correcting the equinus contracture. Tachdjian M: Pediatric orthopaedics , Philadelphia, 1990, Saunders .

30. CONCEPT OF REVERSE PONSETI CASTING??

31. During casting the foot is placed in extreme equino varus position . Forefoot is adducted and inverted while applying upward pressure on the talar head. Congenital Vertical Talus In Freeman- Sheldon Syndrome.Treated with New Method (Reverse Ponseti method ). Mukesh K, Chandrababu K K , Bhaskaran V K

32. PRINCIPLES OF SURGERY: STAGES OF RELEASE AS ADVISED BY TACHDJIAN : FIRST STAGE: reduction of the navicular on the talus by release of the anterior tibialis tendon and the tibionavicular and talonavicular ligaments and capsule . SECOND STAGE : lengthening of the toe extensors and peroneals to allow reduction of the forefoot with calcaneocuboid reduction THIRD STAGE: release of the equinus contracture, lengthening of the Achilles tendon, and division of the ankle and subtalar joint capsules . FOURTH STAGE : transfer of the anterior tibialis tendon to the talus to dynamically stabilize the correction SOMETIMES EXCISION OF NAVICULAR MAY ALSO BE REQUIRED FOR THE REDUCTION

33. TARSAL COALITION: Is an abnormal connection between two or more bones of the foot that may produce pain and limitation of foot motion. Fifty percent to 60% of tarsal coalitions are bilateral. Incidence varies from 0.03% to 1.0 %. Tarsal coalition, rigid pes planus, and peroneal muscle spasm frequently are discussed together as essential components of peroneal spastic pes planus. Tachdjian’sPediatricOrthopaedics,5 th edition

34. TYPES OF TARSAL COALITIONS Calcaneonavicular : more common form but less symptomatic Talocalcaneal : more symptomatic form Other rare forms :calcaneocuboid, naviculocuboid , naviculocuneiform , or massive tarsal coalition Although the exact cause is not known but genetic mutations with autosomal dominant pattern of inheritance has been noted

35. ASSOCIATIONS Cavovarus deformity and talipes equinovarus Fibular hemimelia : “ball-and-socket” ankle Nievergelt-pearlman Syndrome: massive tarsal and carpal coalitions Apert Syndrome Tachdjian’sPediatricOrthopaedics,5 th edition

36. SYNDROMIC COALITIONS Tachdjian’sPediatricOrthopaedics,5 th edition

37. CLINICAL FEATURES.. Symptoms : Usually become symptomatic at /after 12-16 yrs of age Pain- often over the tarsal sinus, beneath the medial malleolus, along the arch of the foot, or occasionally on the dorsum of the foot exacerbated by vigorous sports activities, particularly running on uneven surfaces Stiffness of the hindfoot Frequent ankle sprains Progressive deformity of foot: flat foot Tachdjian’sPediatricOrthopaedics,5 th edition

38. Signs : Flat foot appearance , with external rotation of foot , and abduction of forefoot Restricted ROM of hindfoot ( subtalar inversion and eversion) * Joint motion is more preserved in calcaneonavicular coalition Ill sustained clonus on passive inversion Increased foot progression angle, loss of hindfoot inversion occurs during a toe rise Tachdjian’sPediatricOrthopaedics,5 th edition

39. IMAGING.. X ray : views of feet that are performed are : 45 degree lateral to medial oblique view: to visualise calcanenavicular coalition Harris view : to visualise talocalcaneal coalition across medial subtalar joint Lateral view of foot : to see for elongated anterior projection of the calcaneus, the so-called anteater’s nose , an anterior beak on the talus

40. OTHER IMAGING MODALITIES.. CT SCAN: Best imaging modality for the diagnosis of coalition Denotes extent and type of coalition Based on CT, KUMAR et al .classified coaitions into : type I- osseous, type II- cartilaginous, type III- fibrous * non osseous are more symptomatic Role of MRI: useful in fibrous coalitions and when CT is nondiagnostic Role of tecnetium bone scan: increased uptake in areas of subtalar joint Tachdjian’sPediatricOrthopaedics,5 th edition

41. TREATMENT Options include : Conservative treatment: use of a firm orthosis, 4- to 6-week period of immobilization in a short-leg walking cast Surgery : I ndication : failure to relieve symptoms from a trial of conservative treatment The surgical options include : Resection of coalition and interposition of soft tissue in gap Limited hindfoot fusion Triple arthrodesis- useful in cases of degenerative changes

42. RESECTION OF CALCANEONAVICULAR BAR MIDDLE FACET TALOCALCANEAL COALITION RESECTION

43. ACCESSORY NAVICULAR: 1605, Bauhin first described the accessory navicular. Aka accessory scaphoid, accessory navicular, prehallux , and os tibiale externum An accessory navicular is a congenital anomaly in which the tuberosity of the navicular develops from a secondary center of ossification and located on the medial aspect of the arch in association with the navicular.

44. WHY IS ACCESSORY NAVICULAR IMPORTANT IN DISCUSSING PES PLANUS?? Kidner’s hypothesis states that flatfoot deformity in presence of an accessory navicular had one of three causes : Alteration of the line of pull of the posterior tibial tendon as a result of prominence created by accessory navicular Forcing of the posterior tibial tendon by the accessory navicular to become more of an adductor than a supinator of the forefoot, thereby decreasing support for the longitudinal arch; Impingement of the accessory navicular against the medial malleolus as the foot adducts, which tends to keep the foot in an abducted position and thus partially flattens the longitudinal arch. Mann’s Surgery Of The Foot And Ankle Ninth Edition

45. TYPES Three types are described:COUGHLIN Type I : small, well defined, not attached to navicular, probably sesamoid in tibialis posterior Mann’s Surgery Of The Foot And Ankle Ninth Edition

46. Type II: definite part of the body of the navicular, but the tuberosity is separated by a fibrocartilaginous plate of irregular outline >> so basically a synchondrosis Sella and Lawson have divided the type II into two more types as: Type IIA Type IIB under a tension force a shearing force more at risk for an avulsion injury so more at risk of shear fractures Sella E, Lawson J: Biomechanics of the accessory navicular synchondrosis, Foot Ankle 8:156–163, 1987.

47. Type III : united by a bony ridge, producing a cornuate navicular. Mann’s Surgery Of The Foot And Ankle Ninth Edition

48. CLINICAL FEATURES.. Can become symptomatic in childhood or early adulthood In children, the symptoms are usually caused by pressure of the accessory bone against the shoe. At times, the condition is associated with progressive flattening of the longitudinal arch. In adults, symptoms usually develop after trauma to the foot, often resulting from a twisting injury.

49. IMAGING.. Mann’s Surgery Of The Foot And Ankle Ninth Edition

50. TREATMENT OPTIONS.. NON SURGICAL OPTIONS: In cases of asymptomatic accidental findings- reassurance Shoe changes to reduce pressure over the area In acutely symptomatic cases after an injury - immobilization in a below-knee walking cast, followed by the use of a longitudinal arch support Occasionally use of steroid may provide a relief

51. SURGICAL OPTION : THE KIDNER PROCEDURE A procedure involving the excision of the accessory navicular with or without the plication of posterior tibial tendon. Posterior tibial tendon is detached from the insertion on navicular and rerouted in plantar to dorsal direction and sutured on itself or surrounding periosteum. Rerouting is necessary only when there is pes planus. Sometimes medial slide osteotomy of proximal fragment of calcaneum is also added.

52. Mann’s Surgery Of The Foot And Ankle Ninth Edition

53. DISORDER OF POSTERIOR TIBIAL TENDON AND PES PLANUS.. The main functions of posterior tibial tendon are: plantar flexion of ankle , inversion of foot and stabilization of the medial longitudinal arch Insufficiency of PTT can be caused by : chronic tenosynovitis loss of continuity of the tendon loss of the normal anatomical relationships of the tendon to its insertion Campbell’s Operative Orthopedics,12 th Ed.

54. THE CHANGES THAT FOLLOW INCLUDE: Spring ligament - significant stretching and elongation Anterior or tibionavicular portion of the superficial deltoid ligament- elongate(MEDIAL ANKLE INSTABILITY) Ligaments over naviculocuneiform and cuneiform first metatarsal- elongate

55. CLASSIFICATION Originally developed by Johnson and Strom in 1989 STAGES FEATURES I TENOSYNOVITIS; TOE RAISE TESTS POSSIBLE II LOSS OF PTT FUNCTION;HIND FOOT REMAINS FLEXIBLE III FIXED HINDFOOT DEFORMITY (VALGUS);DEGEN. CHANGES MAY BE SEEN IV VALGUS POSITIONING AND INCONGRUENCY OF ANKLE JOINT INCLUDING STAGE III FEATURES Campbell’s Operative Orthopedics,12 th Ed.

56. CLINICAL FEATURES… SYMPTOMS: Primary complaint is pain-initially medially but later on localised to lateral side Foot and ankle fatigue after only limited activity Gradual or acute onset deformity of foot SIGNS: Flat foot deformity Absence of heel varus on toe raise test Altered gait pattern- absence of end stance hind foot varus position Posterior tibial edema sign( Deorio et al.)

57. IMAGING.. X RAY: Provides inferences to MLA loss, forefoot abduction, TA cont. Helps in ruling out the other causes of MLA loss But, may be normal even with complete rupture of tendon WHAT TO SEE IN X RAYS?? TALUS FIRST METATARSAL ANGLE LOSS OF HEIGHT OF MEDIAL CUNEIFORM OVERLAPPING METATARSALS

58. MIMICKERS Campbell’s Operative Orthopedics,12 th Ed.

59. ROLE OF MRI.. TO SEE FOR THE PERITENDINOUS FLUID COLLECTION, CYSTIC DEGENERATION AND DISTORTED ANATOMY

60. TREATMENT PRINCIPLES.. STAGES TREATMENT OPTIONS STAGE I Rest, nonsteroidal anti-inflammatory agents, and a short-leg walking cast Corticosteroid injection Physiotherapy Brace-medial heel wedge and medial forefoot post (TO KEEP HINDFOOT NEUTRAL) Rarely tenosynovectomy STAGE II Orthotic devices Physiotherapy Surgical reconstruction-FDL/FHL transfer w/o PTT augmentation, spring ligament repair/reconstruction, lateral column lengthening Campbell’s Operative Orthopedics,12 th Ed.

61. Contd.. STAGES TREATMENT OPTIONS STAGE III Orthotic devices Arthrodeses - isolated talonavicular , talonavicular and calcaneocuboid arthrodesis, triple arthrodesis, and isolated subtalar arthrodesis, isolated medial column arthrodesis( Greisberg et al.) STAGE IV Orthotic treatment Arthrodeses - ankle/ tibiotalocalcaneal /triple Ankle arthroplasty - if hindfoot deformity can be corrected Minimally invasive deltoid ligament recon. with triple arthrodesis However it needs to be remembered that the procedures may need to be combined as situation demands

62. SUMMARY.. Pes planus is the presentation of various pathologies in foot that lead to alteration medial longitudinal arch support. Most important thing in evaluating a case of pes planus is finding out whether it is flexible or rigid. Understanding the pathoanatomy of condition requires the knowledge of biomechanics of feet and anatomical variations in foot. Patient may present with pain or deformity of foot . Treatment options vary from mere counselling to very difficult procedures like extensive soft tissue release and bony alignment.