Pes planus and pes valgus

Presentation on Pes planus/Flat Foot for Orthopaedics Residents and Medical students

1. PES PLANUS AND PES VALGUS Presenter : DR. BiJAY Mehta Moderator : dr. GYANENDRA VIKRAM SHAH

2. CONTENTS INTRODUCTION ANATOMY OF THE ARCHES OF FOOT COMMON CAUSES FLEXIBLE FLAT FOOT CONGENITAL VERTICAL TALUS TARSAL COALITION ACCESSORY NAVICULAR POSTERIOR TIBIAL TENDON DISORDER SUMMARY

3. FLAT FOOT : INTRODUCTION Condition in which the medial arch of the foot is diminished or absent, allowing the entire sole to touch the ground . Can be Asymptomatic/Symptomatic Flexible/Rigid/Compensatory

4. INCIDENCE 23 % of adult population . Of this , approximately two thirds have a flexible flatfoot . Approximately one fourth of flatfeet exhibit a contracture of the triceps surae associated with an otherwise typical hypermobile flatfoot The remainder of flatfeet are characterized by more rigidity of the subtalar joint, typically seen with tarsal coalitions.

5. CLINICAL FEATURES 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 “ T oo many toes sign ”

6. ARCHES OF FOOT The springboards and shock absorbers of foot. There are three main arches of foot : M edial longitudinal arch L ateral longitudinal arch T ransverse arch

7. MEDIAL LONGITUDINAL ARCH Arch –Why?? Segmented structure supports weight best if built in form of arch Highest and most flexible arch Acts as shock absorber Helps in propulsion of the foot while walking

8. SUPPORTS OF MLA 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 Ant pillar : 3 metatarsal heads Post pillar : medial calcaneal tubercle

9. FLAT FOOT : CAUSES

10. Common childhood complain Arch is usually obscured in an infant’s foot because of subcutaneous fat . Usually disappears between 4 to 10 years when longitudinal arch develops. “usual in infants, common in children, and within the normal range in adults”- Staheli and Colleagues FLEXIBLE FLATFOOT

11. M ay be associated with ligamentous laxity- look for Beighton score Needs to be differentiated from CALCANEOVAVALGUS Calcaneovalgus Rigid flatfoot Incidence-30% Packaging disorder FLEXIBLE FLATFOOT

12. Painless most of the times . Usually noticed by parents, grandparents or assistants in the shoe shop On Inspection : excessive eversion during weight bearing, the forefoot is abducted , with a midfoot sag with lowering of the longitudinal arch medial column appears longer than the lateral column On Palpation : talar head and navicular tuberosity appear to be in contact with the floor CLINICAL FEATURES

13. Movement : may have increased mobility of ankle or subtalar joint Tests : Tip toe test : Inversion of the heels and arch reconstitution during toe standing Jack’s Test/ Hubscher’s Test : Dorsiflexing the great toe restores the arch CLINICAL FEATURES

14. IMAGING Usually not required Done to rule out causes of the deformity other than idiopathy 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

15. XRAY : MEASUREMENTS C alcaneal pitch angle (α ): formed by the horizontal line and a line from the base of heel and inferior cortex of calcaneus, and less than 20° is considered to represent pes planus . Meary’s angle (β ) : angle between the lines from the centers of longitudinal axes of the talus and the first metatarsal. More than 4° is considered as pes planus Lateral talocalcaneal angle(γ ) : angle formed by the intersection of the line bisecting the talus with the line along the lower border of the calcaneus. An angle over 45° indicates hindfoot valgus, a component of pes planus T alonavicular coverage angle (δ) : Angle between a line connecting the edges of the  articular surface  of the talus a line connecting the edges of the articular surface of the navicular , greater than 7° indicates lateral talar   subluxation T alo -first metatarsal angle (dashed line) : formed by drawing a line through the midaxis of the talus; if this line is angled medial to the first metatarsal, it indicates pes planus .

16. FLAT FOOT : TREATMENT SURGERY VS CONSERVATIVE Indications for surgery Intractable symptoms unresponsive to shoe or orthotic modifications In individuals who are unable to modify the activities that produce pain

17. FLEXIBLE FLATFOOT : TREATMENT Conservative Treatment N o treatment required in an asymptomatic pediatric patient. Education and reassurance are the mainstays. If an Achilles tendon contracture is present- stretching exercises -both active and passive

18. R ole of o rthose s Traditionally used in all patients But t here 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 .

19. SURGICAL TREATMENT : OPTIONS Arthroereisis - limits the amount of valgus motion in the subtalar joint by using an interposition peg Lateral column lengthening Heel cord lengthening Imbrication of talonaviculocuneiform complex Subtalar fusion - only as salvage procedure . Triple arthrodesis

20. Lateral column lengthening Talonaviculocuneiform imbrication

21. CONGENITAL VERTICAL TALUS A cause of rigid pes planus C haracterized by a fixed dorsal dislocation of the talonavicular joint in conjunction with rigid hindfoot equinus R ocker bottom deformity Aka congenital convex pes valgus, teratologic dorsolateral dislocation of the talocalcaneonavicular joint 1 in 10000 live births

22. ETIOLOGY Exact etiology unknown Likely causes Abnormal variation in muscle fibre size Congenital vascular abnormalities Arrest in fetal development of foot at 7-12 weeks POG Autosomal dominant pattern of inheritance Gene mutations (HOXD10 )

23. 60% associated with other congenital anamolies ASSOCIATIONS

24. PATHOANATOMY Hindfoot in equinus Calcaneum and talus in equinus Contracture of Achilles tendon Forefoot in Dorsiflexion Dorsal dislocation of talovicular joint Navicular lies onto neck of talus Contracture of foot dorsiflexors In Total – Convex Platar Deformity

25. 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 Posterior tibial and peroneal tendons may be displaced anteriorly so that they act as dorsiflexors rather than plantar flexors . PATHOANATOMY

26. CLINICAL FEATURES ON INSPECTION: a rocker bottom foot, the apex of which is at the talar head callosities may be seen hindfoot foot is everted into a valg us forefoot is abducted and dorsiflexed ON PALPATION: 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

27. IMAGIN G: XRAY LATERAL PROJECTION : Neutral Maximum Dorsiflexion Maximum Plantarflexion Differentiate from Oblique Talus - Talus aligns with 1 st metatarsal in maximum plantarflexion

28. NORMAL FOOT CVT FOOT

29. TREATMENT EARLIER BELIEF : Major reconstructive surgery was necessary to correct the deformities But resulted in substantial complications - STIFFNESS RECENT BELIEF : Serial casting (described by Dobb) to stretch the contracted dorsal and lateral soft tissues gradually reduce the talonavicular joint followed by M inimally invasive procedures for final correction .

30. Reverse Ponsetti Casting Serial 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

31. PRINCIPLES OF SURGERY: Staged Surgery 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

32. TARSAL COALITION A n abnormal connection between two or more bones of the foot P roduce pain and limitation of foot motion. Incidence varies from 0.03% to 1.0 %. 50 to 60% of tarsal coalitions are bilateral . Tarsal coalition, rigid pes planus, and peroneal muscle spasm - components of peroneal spastic pes planus .

33. TYPES OF TARSAL COALITIONS Calcaneonavicular : mo st common form but less symptomatic Talocalcaneal : more symptomatic form Other rare forms : calcaneocuboid , naviculocuboid, naviculocuneiform, or massive tarsal coalition Etiology: Failure of normal segmentation of fetal tarsal A utosomal dominant inheritance

34. ASSOCIATIONS Cavovarus deformity and talipes equinovarus Fibular hemimelia: Asymptomatic Tarsal coalitions Nievergelt-pearlman Syndrome: massive tarsal and carpal coalitions Apert Syndrome

35. SYNDROMIC COALITIONS

36. CLINICAL FEATURES Symptoms : Usually become symptomatic around 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 Stiffness of the hindfoot Frequent ankle sprains Progressive deformity of foot: flat foot

37. 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 Increased foot progression angle, L oss of hindfoot inversion occurs during a toe rise

38. IMAGING.. X - ray : views usually performed are : 45 degree lateral to medial oblique view: to visualise calcane o navicular coalition Harris axial 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

39. IMAGING 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 MRI : useful in fibrous coalitions and when CT is nondiagnostic

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

41. RESECTION OF CALCANEONAVICULAR BAR MIDDLE FACET TALOCALCANEAL COALITION RESECTION

42. ACCESSORY NAVICULAR First described by Bauhin in 1605 Aka accessory scaphoid, accessory navicular, prehallux, and os tibiale externum 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.

43. ACCESSORY NAVICULAR AND FLAT FOOT Kidner’s hypothesis : Flat foot in presence of an accessory navicular had one of three causes: Alteration of the line of pull of the posterior tibial tendon 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.

44. TYPES Three types described by COUGHLIN Type I : small , not attached to navicular, probably sesamoid in tibialis posterior Type II: definite part of the body of the navicular , separated by cartilaginous plate

45. Type III : united by a bony ridge, producing a cornuate navicular.

46. CLINICAL FEATURES Asymptomatic –most of the time Can become symptomatic in childhood or early adulthood In children, the symptoms are usually caused by pressure of the accessory bone against the shoe. P rogressive flattening of the longitudinal arch . In adults, symptoms usually develop after trauma to the foot, often resulting from a twisting injury.

47. IMAGING

48. TREATMENT NON SURGICAL OPTIONS: In cases of asymptomatic incidental 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

49. SURGICAL OPTION : THE KIDNER PROCEDURE E xcision 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.

50. POSTERIOR TIBIAL TENDON INSUFFICIENCY(PTTI) Most Common cause of adult flat foot The main functions of posterior tibial tendon are: plantar flexion of ankle , inversion of foot stabilization of the medial longitudinal arch

51. PATHOGENESIS

52. CLASSIFICATION Originally developed by Johnson and Strom in 1989 Modified bty Myerson et al. STAGES FEATURES I TENOSYNOVITIS; NO DEFORMITY , TOE RAISE TESTS POSSIBLE II LOSS OF PTT FUNCTION;HIND FOOT VALGUS, BUT FLEXIBLE III FIXED HINDFOOT DEFORMITY (VALGUS);DEGEN. CHANGES MAY BE SEEN IV VALGUS POSITIONING AND INCONGRUENCY OF ANKLE JOINT INCLUDING STAGE III FEATURES

53. PTTI : RISK FACTORS Obesity Pre-Existing Flat foot Diabetes Increasing age Corticosteroid Use Seronegative Inflammatory disorders

54. CLINICAL FEATURE S STAGE I : Inflammation P ain-initially medially but later on localised to lateral side , Swelling Tenderness over Tib post Loss of medial longitudinal arch Can do single heel test STAGE II : Tib post rupture Pain, swelling Heel Valgus Deformity-Flexible Can’t do Single heel raise test , but can do double heel raise

55. STAGE III : Fixed Deformity Pain-both medial and lateral side Fixed flat foot Stiff Subtalar joint

56. IMAGING X RAY: Provides inferences to MLA loss, forefoot abduction, Helps in ruling out the other causes of MLA loss But , may be normal even with complete rupture of tendon USG To look for PTT Rupture MRI To see for the peritendinous fluid collection, cystic degeneration and distorted anatomy

57. TREATMENT STAGES TREATMENT OPTIONS STAGE I Rest, NSAIDs, Physiotherapy Corticosteroid injection Orthosis Rarely tenosynovectomy STAGE II Orthotic devices , Physiotherapy Surgical reconstruction-FDL/FHL transfer to augment PTT S pring ligament repair/reconstruction , L ateral column lengthening

58. Contd.. STAGES TREATMENT OPTIONS STAGE III Orthotic devices Arthrodeses-isolated talonavicular, talonavicular and subtalar arthrodesis, triple arthrodesis STAGE IV Orthotic treatment Arthrodeses- ankle/tibiotalocalcaneal/triple Ankle arthroplasty - if hindfoot deformity can be corrected

59. SUMMARY Pes planus - presentation of various pathologies - lead ing to alteration medial longitudinal arch support. Most important step for management - find 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.

60. REFERENCES:

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