Pes planus / Flat Foot

Collapse of medial longitudinal arch, with the entire sole of the foot coming into complete or near-complete contact with the ground.

Books Refered :
Text Book Of ANATOMY - Vishram Singh
Joint Structure And Function – Cynthia Norkin
Therapeutic Exrercise – Carolyn Kisner
Orthopaedic Physical Assessment – Magee
Orthopaedic Medicine – L. Ombregt
Campbell’s Operative Orthopaedics

1. PES PLANUS SALONI PATIL [ 3 rd year BPT ]

2. INDEX DEFINITION ANATOMY BIOMECHANICS COMPONENTS OF FLAT FOOT SECONDARY CHANGES RADIOLOGICAL FEATURES ETIOLOGY ORTHO ASSESSMENT OF FLAT FOOT *SUBJECTIVE *OBJECTIVE *SPECIAL TEST *INVESTIGATION *PROBLEM LIST *GOALS MEDICAL MANAGEMENT CONSERVATIVE MANAGEMENT INDICATIONS FOR SURGICAL TREATMENT SURGICAL / OPERATIVE PROCEDURES POST OPERATIVE PT MANAGEMENT

3. SYNONYMS - Flat Feet - Pes Planovalgus - Fallen Arches - Pronation of feet DEFINITION Collapse of medial longitudinal arch, with the entire sole of the foot coming into complete or near-complete contact with the ground .

4. ANATOMY OF MEDIAL LONGITUDINAL ARCH Formed by the Calcaneum , Talus, Navicular , three Cuneiforms & three Metatarsals. Characteristic feature is RESILIENCY ( Capacity to recover quickly from any injuries) Factors maintaining the Medial Longitudinal Arch : BONE - Sustentaculum Tali supports the head of Talus. LIGAMENTS- a) Spring Ligament – provides dynamic support to head of talus. b) Interosseous Lig . – connecting adjacent bones. c) Interosseous Talo-calcanean Lig .

5. MUSCLES, TENDONS & APONEUROSIS- A] Acting as Slings [ suspension of arch from above] Tibialis Posterior Tendon : *Provides Dynamic support to Head of Talus *Suspends the arch from above . Tendon of Flexor Hallucis Longus : *Stretches the arch *Supports Calcaneus & Talus B] Acting as Tie Beams [preventing separation of the pillars ] The medial part of plantar aponeurosis + Abductor Hallucis assisted by Flexor Hallucis Brevis – acts as tie beam to maintain the height of the medial longitudinal arch.

6. FLAT FOOT RESULTS IN – *Relatively over mobile foot (which requires muscular contraction to support the arches during standing ) *Increased weight bearing on the 2 nd to 4 th metatarsal heads ( plantar callus formation ) *Weight-bearing pronation in erect standing posture causes medial rotation of tibia ( may affect knee joint function )

7. BIOMECHANICS TWO TYPES- Rigid Flat Foot – MLA is absent in Non-weight bearing, Toe Standing, and in Normal weight bearing situation. Flexible Flat Foot – MLA is reduced during Normal weight bearing but reappears during Toe Standing and Non-weight bearing situation Depression and pronation of the Calcaneus and depression of the Navicular bone Tension in spring ligament Lengthening of Tibialis Posterior Muscle ESTIMATION OF EXTEND OF FLAT FOOT – Note the location of navicular bone in relation to the head of first metatarsal. **Normally the Navicular bone is intersected by the Feiss Line. In case of flat foot, the Navicular bone is depressed ( i.e. it lies below the Feiss Line)

8. COMPONENTS OF FLAT FOOT Forefoot Abduction & Supination Talar head Displaced medially, anteriorly, and downwards Calcaneum Everts , dorsiflexes – hindfoot is in valgus Navicular Subluxates dorso -laterally

9. SECONDARY CHANGES Navicular , Cuneiform, Cuboid becomes wedge shaped, with apex directed dorso -laterally. Plantar, Spring and Deltoid ligaments are stretched. Anterior, Pọsterior Tibial tendons & plantar muscles are stretched whereas the Achilles tendon & Peronei become shortened. Callus develops over the medial bony prominences .

10. RADIOLOGICAL FEATURES Collapse of the longitudinal arch Hind foot Valgus Forefoot Abduction

11. ETIOLOGY Rigid flat foot Flexible flat foot Developmental Hypermobile ( ligamentous hyperlaxity ) Neurogenic CONGENITAL FLAT FOOT ACQUIRED FLAT FOOT Pes planovalgus Adult Flexible Flat Foot Congenital Vertical Talus Tarsal Coalition Tendon Dysfunction Iatrogenic Arthritic Charcot Foot / Neuromuscular Flat Foot

12. ORTHOPAEDIC ASSESSMENT OF FLAT FOOT A] DEMOGRAPHIC DATA Occurs in all age group In adults; most common in women over 40 years of age B] CHIEF COMPLAINT Painless most of the times. Patient may complaint of ; *Abnormal appearance of the foot *Difficulties with shoewear , walking, running. *Pain beneath the medial malleolus, along the arch of the foot or on the dorsum of the foot *Pain may aggravate by vigorous sports activities ( running on uneven surface ) *Stiffness if hindfoot * F requent ankle sprains *Restriction of hindfoot ROM ( subtalar inversion & eversion )

13. C ] HISTORY Usually bilateral and asymmtomatic and painless. Pain at rest, numbness, weakness, polyarticular pain, constitutional symptoms. Age and any history of trauma. Limping, inability to weight bear. Ask for developmental history D] BODY CHART Area – Foot and Ankle Onset – Gradual / Insidious Type – Dull Aching Depth – Deep Constancy – Intermittent

14. E] AGGRAVATING FACTOR – prolonged standing and during activities of daily living. F] RELIEVING FACTOR – Rest, G] SEVERITY – Vas Scale H] IRRITABILITY – Moderate I] 24 HOURS PATTERN J] PAST HISTORY – Ask for a ny h/o trauma K] MEDICAL HISTORY – Down’s , Marfan’s , Osteogenesis Imperfecta , Polio. L] FAMILY HISTORY – Of Flat Feet and Joint Hypermobility. M] SOCIAL HISTORY – Work / Sports / Hobbies affected N] ECONOMIC HISTORY – Modified KuppuSwamy Scale.

15. OBJECTIVE ASSESMENT OBSERVATION POSTURE - foot posture in standing and arch posture Deformity - is there any deformity present such as bunions, hammer toes, claw toes, calluses, hindfoot valgus etc PALPATION Joint Lines Medial and lateral ligament Achilles tendon, peronei and other extrinsic muscles

16. GAIT Gait Analysis  - walking normally, on insides and outsides of feet, walk on heels and toes, in a straight line, running (particularly if pain present on running ) SR.NO. TITLE AUTHOR METHODOLOGY CONCLUSION 1. Kinematic Analysis of the Lower Extremities of Subjects with Flat Feet at Different Gait Speeds Myoung -Kwon Kim ,  Yun- Seop Lee This study determined the difference between flat feet and normal feet of humans at different gait velocities using electromyography (EMG) and foot pressure analysis. [Subjects] This study was conducted on 30 adults having normal feet (N = 15) and flat feet (N = 15), all of whom were 21 to 30 years old and had no neurological history or gait problems. [Methods] A treadmill (AC5000M, SCIFIT, UK) was used to analyze kinematic features during gait. These features were analyzed at slow, normal, and fast gait velocities. A surface electromyogram ( TeleMyo 2400T, Noraxon Co., USA) and a foot pressure analyzer (FSA, Vista Medical, Canada) were used to measure muscle activity changes and foot pressure, respectively. Because muscle activation has a tendency to increase with an increase in gait velocity, we hypothesized that the lower extremity with a flat foot requires more work to move due to the lack of a medial longitudinal arch, and consequently pressure was focused on the 2nd–3rd metatarsal area during the stance phase Article link -- https ://doi.org/10.1589/jpts.25.531

17. ROM TESTING *AROM and PROM - ankle, subtalar joint, midfoot , forefoot and toes. *Lower limb muscle length Test FUNCTIONAL ASSESMENT ( Oswetry disability index - ODI ) (Patient specific functional scale – PSFS)

18. MMT & ROM

19. SPECIAL TEST “ Too many toes sign ” Navicular Drop Test Toe Raising Test Fore-Foot Heel Alignment Jack’s Test (  Hubscher’s maneuver  ) Silfverskiöld tes t

20. Special Test: Functional or Structural Pes Planus  PROCEDURE:   • Therapist observes ( and compares) the orientation of the patient’s MLA while doing each of the following : a. Patient stands straight with both heels and toes on the ground b. Patient stands with just the toes on the ground c. Patient sits on the table  POSITIVE TEST : •  Functional Pes Planus  = if MLA is restored when the patient is either standing on the toes or seated = due to muscle or ligament weakness •  Structural Pes Planus  = if MLA remains flat when the patient is standing on toes and when seated.

21. INVESTIGATION X-RAY : AP and Lateral Views of the foot is taken to evaluate the severity of deformity. Special View – 45 degree eversion oblique for accessory navicular bone. AP standing view is to assess Heel Valgus ( Talo -calcaneal angle > 35 degree is associated with increased heel valgus ) CT SCAN : Accurately defines anatomy of subtalar joint, allows surgical planning if involved.

22. DIAGNOSIS A] Collapse of the longitudinal arch. * Meary’s angle Long axis of Talus should nearly bisect the Navicular & long axis of First Metatarsal through it’s shaft ( on standing lateral X-ray ) Grades – Normal – 0 degree Mild – 0 to 15 degrees Moderate – 15 to 40 degrees Severe – > 40 degrees

23. *Calcaneal Pitch is decreased Normal – 17 to 32 degrees

24. B] Hind foot Valgus : * AP Talo -calcaneal Angle – Angle formed by the intersection of a line bisecting the head of the TALUS and a line running parallel with the lateral surface of the CALCANEUS. Normal Range is 15 – 30 ° Abnormally increased angle > 30 degrees indicates Hind Foot Valgus in pes planus

25. C] Forefoot Abduction : Lateral subluxation of the navicular on the talus is indication of forefoot abduction

26. PROBLEM LIST BODY STRUCTURE & FUNCTION ACTIVITY LIMITATION PARTICIPATION RESTRICTION Pain along the arch and dorsum of foot Inability to weight bear Difficulty while walking, standing and running Hind foot Stiffness Unable to invert or evert while weight bearing Gait Deviation Restricted ROM Walking Limitations Difficulty in daily activities

27. SHORT TERM GOALS LONG TERM GOALS To relieve Pain Pain free Ambulation To reduce stiffness Gait training To increase ROM at Talus- crural joint, Subtalar joint, Calcaneo -cuboid joint and Transverse tarsal joint. Strengthening of weak muscles To mobilize the callus formed Argonomics

28. MEDICAL MANAGEMENT Analgesics & NSAIDs are the common pain relieving medications.

29. CONSERVATIVE MANAGEMENT 3-9 Years : Conservative Management No Surgery Custom orthosis inserted with leather, cork, propylene. Physiotherapy Physiotherapy – Gastrocnemius Stretching, Tibialis posterior and Intrinsic muscles Strengthening . 10-14 Years : If there are No symptoms – No treatment is needed. Symptomatic – Initially conservative management Orthosis Physiotherapy Surgery

30. FOOT ORTHOSES

31. INDICATION FOR SURGICAL TREATMENT Persistent pain and Ulceration or Callus under the head of the plantar flexed talus and interferes with normal daily activities. Rigid and painful flatfoot. To prevent progression in neuropathic ( charcot joint ) Tibialis posterior dysfunction.

32. OPERATIVE PROCEDURES Achilles tendon or gastrocnemius fascia lengthening Evans Calcaneal Lengthening osteotomy Talonavicular reduction and pinning Talectomy Triple Arthrodesis

33. Achilles tendon or gastrocnemius fascia lengthening TA Lengthening – Percutaneous & Z lengthening Gastrocnemius Recession

34. Evans Calcaneal Lengthening osteotomy Lengthening of lateral column of the foot by inserting bone graft and calcaneocuboid fusion.

35. Triple Arthrodesis Usually done after the age of 12-13 years. Has a 50% failure rate in children under 10 years of age. Joints fused are : Subtalar joint. Calcaneo - Cuboid joint. Talo Navicular joint.

36. COMPLICATIONS OF SURGERY Non-union Degenerative joint disease Avascular Necrosis Lateral Instability Stiff Foot

37. POST OPERATIVE PHYSICAL THERAPY MANAGEMENT DAY 1-7 POST OP Patient education & advice Education of precautions & contra-indications Non weight bearing immobiliztion Bed Exercises : *Upper limb exercises to stimulate the cardiac function * Maintenance of non-operated leg 2 WEEEKS POST OP Removal of cast Replaced with posterior orthosis , a removable cast boot or CAM boots that allows free plantarflexion but restricts dorsiflexion to -20 degree. Partial weight bearing ambulation with bilateral axillary crutches Prevent stiffness

38. 2-4 WEEKS POST OP Same CAM Orthosis continued. Weight bearing as tolerated in walking boot or CAM orthosis , crutches as needed 4-6 WEEKS POST OP CAM orthosis that allows free plantarflexion but restricts dorsiflexion to 10 degree ( week 4) and 0 degree (week 5). Full weight nearing in walking boot. 6-8 WEEKS POST OP CAM orthosis that allows free plantarflexion but restricts doriflexion to 10 degree (week 6). Wean from CAM orthosis to shoes with 1 to 1.5cm bilateral heel lift (week 7). Full weight bearing to functional brace or shoe with heel lift. 8 WEEKS POST OP Wean from heel lifts by 10 weeks. Full weight bearing in regular shoe without lifts by 10 weeks.

39. POST OP EXERCISES STRETCHING EXERCISES Initiate AROM dorsiflexion within the protected range by week 3. Limit DF to no more than 10 degree beyond neutral until 8 weeks after surgery. Progress to full ankle DF by 12 weeks. Initiate weight bearing stretches in sitting with feet on the floor, a low incline wedge (< 10 degree). Begin standing stretches in bilateral stance with knees bent, only if pain free, which is accomplished with a modified runners wall stretch or a low incline (<10 degree) wedge. RESISTANCE EXERCISES Begin strengthening exercises for ankle and foot musculature in non weight-bearing positions against low loads before progressing to closed chain exercises against body weight. Initiate heel raises in a seated position with gradual addition of external resistance before progressing to bilateral heel raises in standing. Progress heel raising/lowering exercises from bilateral to unilateral only if performed pain free by 10 to 12 weeks post-op.

40. REFERENCES Text Book Of ANATOMY - Vishram Singh Joint Structure And Function – Cynthia Norkin Therapeutic Exrercise – Carolyn Kisner Orthopaedic Physical Assessment – Magee Orthopaedic Medicine – L. Ombregt Campbell’s Operative Orthopaedics ARTICLE - Kinematic Analysis of the Lower Extremities of Subjects with Flat Feet at Different Gait Speeds