20. Maintenance of the longitudinal
arches
The longitudinal arches are supported and stabilised
by:
The muscles whose tendons run into the apex of the
arches and tend to increase their height (e.g. tibialis
anterior)
The muscles whose tendons run into the sole of the
foot (e.g. peroneus longus tibialis post. and
smallintrinsic muscles which also run longitudinally
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22. shape of the bones which allows them to interlock
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23. A variety of longitudinally
arranged ligaments which
prevent the extremities
separating, for example the
long and short plantar
ligaments and by the plantar
calcaneonavicular ("spring")
ligament.
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24. The plantar aponeurosis links
the extremities of the arches, and
acts as the equivalent of a tie
beam in an architectural arch.
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29. PES PLANUS AND PES VALGUS
(‘FLAT-FOOT’)
The term ‘flatfoot’ applies when the apex of the arch
has collapsed
and the medial border of the foot is in contact (or
nearly in contact) with the ground;
the heel becomes valgus
and the foot pronates at the subtalar-midtarsal
complex.
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30. 3 components that are involved in producing the
alignment abnormalities of symptomatic adult
flatfoot:
collapse of the longitudinal arch
hindfoot valgus
forefoot abduction
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31. Assesment of these components
Each of these components
can be assessed on either
the lateral or AP view of
the foot.
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32. Assesment of these components
COLLAPSE OF LONGITUDINAL ARCH
Lateral: 1st metatarsal talar angle < 4
Lateral: Calcaneal pitch 18 to 20°
FOREFOOT ABDUCTION
AP: Talonavicular coverage angle
AP: 1st metatarsal talar angle
HINDFOOT VALGUS
Lateral: Talo-calcaneal angle
AP: Talo-calcaneal angle
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33. OTHER SIGNS
AP & Lateral: CYMA line
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37. Lateral talar - 1st metatarsal angle
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38. MILD :greater than 4° convex downward is considered
pes planus
with an angle of 15° - 30° considered moderate , and
greater than 30° severe
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46. CYMA line
A cyma line is an architectural term designating the
union of two curve lines.
A normal midtarsal joint should create a smooth cyma
between the talonavicular joint and calcaneocuboid
joint on both the AP and lateral views (Figures a).
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49. Flexible Pes Planovalgus (Flexible
Flatfoot)
Physiologic variant consisting of a decrease in the medial
longitudinal arch and a valgus hindfoot and forefoot
abduction with weightbearing
Epidemiology
incidence
unknown in pediatric population
20% to 25% in adults
Pathoanatomy
generalized ligamentous laxity is common
25% are associated with gastrocnemius-soleus contracture
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50. NATURAL HISTORY
The arch is usually obscured in an infant's foot because
of subcutaneous fat.
Both footprint[26,39] and radiographic[42] studies of the
child's foot demonstrate that the longitudinal arch
develops during the first decade of life
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51. This observation also leads to the overwhelming
conclusion that prophylactic treatment of a typical
flatfoot is unnecessary, with profound implications for
the corrective shoe and insert–orthosis .
Development of the arch is independent of the use of
such external orthoses or the wearing of corrective
shoes.
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52. Presentation
Symptoms
usually asmptomatic in children
may have arch pain or pretibial pain
Physical exam
inspection
foot is only flat with standing and
reconstitutes with toe walking, hallux
dorsiflexion, or foot hanging
valgus hindfoot deformity
forefoot abduction
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53. recommended viewsrequired
weightbearing AP foot
evaluate for talar head coverage and talocalcaneal angle
weightbearing lateral foot
evaluate Meary's angle
weightbearing oblique foot
rule out tarsal coalition
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55. 10/1/2014
The arch can often be restored
by simply dorsiflexing the great toe
(Jack’s test), and
during this manoeuvre the tibia
rotates externally
(Rose et al., 1985).
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58. Treatment:
Nonoperative
observation, stretching, shoewear modification,
orthotics
indications
asymptomatic patients, as it almost always resolves
spontaneously
counsel parents that arch will redevelop with age
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59. Techniques
athletic heels with soft arch support or stiff soles may be
helpful for symptoms
UCBL heel cups may be indicated for symptomatic relief of
advanced cases
rigid material can lead to poor tolerance
stretching for symptomatic patients with a tight heel cord
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63. Operative
continued refractory pain despite use of extensive
conservative managemen.
Achilles tendon or gastrocnemius fascia
lengthening
If flexible flatfoot with a tight heelcord with painful
symptoms
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65. sliding calcaneal osteotomy
corrects the hindfoot valgus
plantar base closing wedge osteotomy of the first
cuneiform
corrects the supination deformity
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67. Tarsal Coalition & Peroneal Spastic
Flatfoot
Congenital anomaly that leads to fusion of tarsal
bonesand a rigid flatfoot results in syndrome peroneal
spastic flatfoot
most common coalitions are
calcaneonavicular Slide 13
most common
talocalcaneal
talonavicular
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69. The true incidence of tarsal coalition is greater than
the
1% usually quoted.
Tarsal coalition appears to be inherited, probably as a
unifactorial disorder of autosomal dominant .
The specific type of coalition probably represents a
genetic mutation that is responsible for failure of the
primitive mesenchyme to segment
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70. age of onset
calcaneonavicular
8-12 years old
talocalcaneal
12-15 years old
Pathophysiology
mesenchymal segmentation leading to coalition of tarsal
bones
coalition may be
fibrous
cartilagenous
osseous
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71. Associated conditions
multiple coalitions are associated with
fibular deficiency
Apert syndrome
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72. Presentation
Symptoms
pain worsened by activity
onset of symptoms correlates with age of ossification of
coalition
calf pain
secondary to peroneal spasticity
recurrent ankle sprains
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73. Physical exam
inspection & palpationpes planus
collapse of the medial longitudinal arch
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74. The medial border of the foot from just
behind the first metatarsal head to a point about 2 cm
distal to the calcaneal tuberosity
should be elevated from the floor when the subject is
standing.
The apex of this arch is usually about 1 cm.
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75. system for grading
Jack described a general system for grading the morphology
of the medial longitudinal arch.
grade I arch is subjectively slightly depressed
on weightbearing.
grade II arch, the entire medial
border of the foot touches the floor but its edge is
straight.
grade III arch, the entire medial border of
the foot not only touches the floor but also bulges toward
the examiner in a convex manner
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76. Physical exam
inspection
hindfoot valgus
forefoot abduction
range of motion
limited subtalar motion
heel cord contractures
arch of foot does not
reconstitute upon toe-standing
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79. Peroneal spastic pes planus.
Tarsal coalition, rigid pes planus, and peroneal muscle
spasm together as essential components of
Peroneal spasm actually is an acquired or adaptive
shortening of the muscle-tendon units
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80. Stretch reflex of a
shortened muscle-tendon unit
Inversion stress by the examiner, producing an
unsustained three-four-beat clonus of the peroneal
muscles,.
That peroneal muscle tight-ness is the frequent
resultof tarsal coalition and not the cause
must be emphasized
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81. Peroneal muscle tightness is seen in
rheumatoid arthritis, osteochondral fracture,
and infection in the subtalar joint (tuberculous, mycotic, or
pyogenic), or neo-plasm (osteoid osteoma, osteochondroma,
fibrosarcoma) adjacent to the subtalar joint in the talus or
calcaneus.
The relaxed position of the subtalar joint is valgus,
which places the least strain on the talocalcaneal
interosseous
ligament according to Lapidus.
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82. Imaging
Radiographs recommended views
Required
anteroposterior view
standing lateral foot view
45-degree oblique view
most useful for calcaneonavicular coalition
Slide 30
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83. calcaneonavicular coalition
"anteater" sign
elongated anterior
process of calcaneus
talocalcaneal coalition
talar beaking on lateral
radiograph
occurs as a result of
limited motion of the
subtalar joint
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87. CT scan
necessary to
rule-out additional coalitions
determine size and extent of coalition
MRI
may be helpful to visualize a fibrous or cartilagenous
coalition
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89. Treatment
Nonoperative
observation
asymptomatic cases
immobilization with casting or orthotics
initial treatment for symptomatic cases
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90. Operative
surgical resection of coalition with interposition of
fat graft or extensor digitorum brevis
resistant cases when nonoperative management fails to relieve
symptoms
subtalar arthrodesis
triple arthrodesis (subtalar, calcaneocuboid, and
talonavicular)
advanced coalitions that fail resection
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98. What s this shows??
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99. pes planus
Zahid H Malik
ve a nice day
Thanks for your participation
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Editor's Notes
From architecheral point of view … these thing need for a high arch bridge .. Nature as used all these principles.
18 to 20°
CRANIOFACIAL DYSPLASIA The best-known of these conditions is Apert’s syndrome
(acrocephalosyndactyly). The head is somewhat
egg-shaped: flat at the back, narrow anteroposteriorly,
with a broad, towering forehead, depressed face,
bulging eyes and prominent jaw