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. SALONI PATIL [ 3rd 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 2nd to 4th 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-
A) Rigid Flat Foot – MLA is absent in Non-weight bearing, Toe Standing, and in
Normal weight bearing situation.
B) 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
*Frequent 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 any 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.N
O.
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
HIP
Flexors/ion
Extensors/ion
Abductors/ion
Adductors/ion
Internal rotators/ion
External rotators/ion
KNEE
Flexors/ion
Extensors
ANKLE
DF’ors/ion
PF’ors/ion
Invertors/inversion
MMT ROM
MUSCLES/ACTION RIGHT LEFT N.ROM ACTIVE RT ACTIVE LT PASSIVE RT PASSIVE LT

19. SPECIALTEST “Too many toes sign”
• Navicular Drop Test
• Toe Raising Test
• Fore-Foot Heel Alignment
• Jack’s Test ( Hubscher’s maneuver )
• Silfverskiöld test

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

30. FOOT ORTHOSES

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

32. OPERATIVE PROCEDURES
1. Achilles tendon or gastrocnemius fascia lengthening
2. Evans Calcaneal Lengthening osteotomy
3. Talonavicular reduction and pinning
4. Talectomy
5. 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 PHYSICALTHERAPY
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
2WEEEKS 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. 2-4WEEKS POST OP
• Same CAM Orthosis continued.
• Weight bearing as tolerated in walking
boot or CAM orthosis, crutches as
needed
4-6WEEKS 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.
6-8WEEKS 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.
8WEEKS 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