the slide Foot arch deformity give brief description about the anatomy of foot and related deformity.

1. PRESENTATION BY
,
MOHAMMAD AZHARUDDIN,
B.P.T
FOOT ARCH DEFORMITIES

2. WHAT ARE ARCHES AND WHY
THEY ARE IMPORTANT
• Formed by tarsal and metatarsals bones and
strengthened by ligaments and muscles.
• Help in fast walking, running, and jumping. In
addition they help in weight bearing and in
providing upright posture.

3. NATURAL HISTORY OF ARCHES
Initially, we see significantly bowed legs, noticeable out-toeing, and no
evidence of a medial arch.
The arches slowly become more obvious and increase in height as our gait
improves. The foot grows faster than the rest of the body; it achieves three
quarters of its mature length by the time the child is seven years old.
 By six or seven years of age, most children have also developed their adult
medial arch, although some take until age ten or eleven to complete
development

5. FACTORS RESPONSIBLE FOR
MAINTENANCE OF ARCHES
• Shape of the bones.
• Intersegment ties or ligaments and muscles
hold different segments of arch together.
• The beams that connect the two ends of the
arch.
• Slings keep the summit of arch pulled up.

6. FUNCTIONS OF ARCHES
• Body weight distribution.
• Act as a spring which help in walking and
running.
• Act as shock absorber in stepping and
particularly in jumping.
• Concavity of arches protects the soft tissues of
the sole against pressure.

7. FOOT DIVISION
• Hind-foot
• Mid-foot
• forefoot

8. CLASSIFICATION OF ARCHES
• A. Longitudinal
1. medial
2. lateral
• B. TRANSVERSE
1. ANTERIOR
2. POSTERIOR

9. Medial Longitudinal arch
•It is higher than lateral longitudinal arch
•Shock absorber

10. Medial Longitudinal arch Summit of arch
Art. Surf.Talus
Post.pillar
Med.Tub.Calcaneus
Ant.pillar
Heads of 1st to 3rd Met.Tar

12. Lateral Longitudinal arch

14. TRANSVERSE ARCH
Made of prox. By 3 cuneiforms
and cuboid
Distally bases of 5 metatarsals

15. PES PLANUS
Condition in which medial longitudinal arch of foot is diminished or
absent and foot is come in contact with the ground
People with hypertrophied planter foot muscles (lifelong barefoot walkers)
might appear to have flat feet, when their bony arches are normal.
TYPES
1. developmental or acquired
2. Flexible or fixed
IN CHILDREN
1. pes planus can be a part of normal development
2. Abnormal development of foot
IN ADULTS
1. Physiological pes planus
2. Adult acquired pes planus

17. CONTINUE…..
CONTRIBUTING FACTORS
• Footwear: shoes which limit toe movement; high heels.
Barefoot walking may be protective.
• A tight Achilles tendon or calf muscles (heel cord
contracture). This may help to cause PP, or may contribute
to symptoms such as foot pain when there is existing PP.
• Obesity
• Other bony abnormalities, e.g. rotational deformities, tibial
abnormalities, coalition (fusion) of tarsal bones, equinus
deformity.
• Ligamentous laxity, e.g. familial, Down's syndrome.
• Other factors causing foot pronation, e.g. hip abductor
weakness and genu valgum.

18. CONTINUE…
PRESENTATION AND ASSESSMENT
CHILDREN
• History of the PP and any changes.
• Symptoms: walking/running ability and any foot pain.
• Past medical history: other diseases, developmental delay.
ADULTS
• Is the PP new? Is it symmetrical?
• Is there foot pain or interference with walking?
• Are there any other lower limb symptoms, e.g. knee pain?
• Past medical history: injuries, other related disease (neurological, rheumatological,
musculoskeletal).
• Occupation and hobbies.
• If PP is new, asymmetrical or painful, ask about symptoms of tibialis posterior dysfunction,
which are:
– Pain or swelling behind the medial malleolus and along the instep.
– Change in foot shape.
– Decreasing walking ability and balance.
– Ache on walking long distances.

19. CONTINUE…
EXAMINATION
INVESTIGATION
In some cases, standing foot X-rays may be used to show the
degree of deformity:
o Standing lateral view shows the longitudinal arch and
talonavicular joint.
o Standing AP view shows the degree of heel valgus
(talocalcaneal angle).

20. TALONAVICULAR COVERAGE ANGLE
(normal - < 7 degree

21. MEARY’S ANGLE
greater then 4 degree
convex downward indicate
pes planus
15-30 degree - moderate
Greater then 30 - severe

22. CALCANEAL PITCH
Decreased calcaneal pitch is consistent with pes planus

23. MANAGEMENT OF PES PLANUS
• Is treatment necessary?
• NON SURGICAL TREATMENT
- heel cord stretching
- orthotics may be used
- reduce contributing factors
• SURGERY
- Possible surgical procedures include:
- Achilles tendon lengthening.
- Calcaneal osteotomy, to re-align the hind-foot.
- Reconstruction of the tibialis posterior tendon.
- For severe mid-foot collapse of the arch, triple arthrodesis may be
indicated.

27. EXERCISES FOR FLAT FOOT
• Toe clawing
• Toe spreading
• Rising the inner border of forefoot closing – making fist with foot
• Active foot rolling
• Picking up small logs through foot
• Standing on outer borders of foot
• Toe flexion and extension while sanding on the edge of the stairs
with toes of the stairs.
• Walk on a straight line
• Walking on the lateral border of the foot
• Curved foot walking
• Heel walking
• Toe walking

31. Complications and prognosis
• Physiological pes planus (PP)
– It is generally stated that physiological PP is unlikely to
cause significant foot problems.1,3 However, some authors
suggest that excessive foot pronation (which usually occurs
with PP) may contribute to the development of foot pain
and foot problems such as:2
– Tibialis posterior dysfunction (because hyper-pronation
stretches this tendon).
– Hallux valgus (because more weight is borne by the medial
metatarsals when the foot hyper-pronates).
– Metatarsalgia (for the same reason).
– Plantar fasciitis.
– Knee pain
– PP may reduce the shock-absorbing features of the foot,
potentially contributing to low back pain.3

32. PES CAVUS
• Deformity of a high arched.
• Occurs when metatarsals bone are planter-
flexed relative to hind-foot – forefoot plantaris
– which increases the height and curvature of
the longitudinal arch.
• VARIANTS
pes equinocavovarus
pes calcaneovarus

33. AETIOLOGY
• The sole of foot can be conceived as a tripod, consisting of first and fifth metatarsal
head and heel.
• IN PES CAVOVARUS – tibialis posterior and peroneus longus are stronger then
tibialis anterior and peroneus breviS
CAUSES OF PES CAVUS
Progressive neurological disorders
• Hereditary Sensori-motor
Neuropathies (HSMN)
or Charcot-Marie-Tooth disease
(CMT) (78%)3
• Hereditary sensory and
autonomic neuropathies
• Friedreich ataxia
• Spinal or brain Tumor
• Spinal muscular atrophy

34. Other causes
• Scarring of the deep posterior compartment
after compartment syndrome5
• Foot trauma
• Tarsal coalition
• Under-corrected congenital talipes equinovarus
• Iatrogenic (e.g. overzealous surgery for pes
planus)
• Idiopathic / familial
Static
neurological
disorders
• Cerebral palsy
• Stroke
• Poliomyelitis
• Spinal nerve
root injury
• Peroneal nerve
injury4
• Spinal trauma
• Syringomyelia
• Myelodysplasia
• Spinal dysraphism: spina bifida, spina bifida
occulta, diastematomyelia4
• Muscular dystrophy

35. SYMPTOMS
Metatarsal overload, heel pain. Stiffness, ankle sprain, ill fitting footwear, foot
rubbing, ulceration
Reduce shock absorbance and diminish ability to balance on uneven surfaces
Hind-foot varus lead to increase moment on ankle, making ankle inversion
injuries common eventually there may be dramatic varus tilting and secondary
osteoarthritis.
Planter pain and callus formation may give way to ulceration particularly in
patients with sensory loss.
With progression ---deformity and rigidity become more severe
Lateral foot overload 5th metatarsal stress fracture.
Achilles tendon disorders, plantar fasciitis, and ankle impingement are also
common.

36. DIAGNOSIS
• HISTORY
• Family history
• Birth and early developmental history
• Previous trauma / illness / injury
• General examination may reveal features of neurological conditions such as
path of hair over spine in spina bifida.
• Neurological examination - search for signs of peripheral, nervous disease, such
as muscle wasting, weakness and sensory deficit, and signs of central nervous
disease, such as pyramidal signs, cerebellar signs or cranial nerve
abnormalities. Accurate serial recording of power in individual muscle
groups.
• FOOT EXAMINATION – to what extent deformities are fixed or flexible.
Examination include :
inspection, palpation, passive and active movements,
looking for joint contractures, ‘ COLEMAN BLOCK TEST’,
• INVESTIGATIONS : Radiographs, nerve conduction testing and EMG.
if onset is during adulthood or rapidly progressive a central
disorder mus t be excluded by MRI of brain an spinal cord.

37. CONSERVATIVE
Suggested conservative management of patients with
painful pes cavus typically involve :
• Strategies to reduce and redistribute plantar
pressure loading with
 foot orthoses and
 specialized cushioned footwear
• Stretching and strengthening of tight and weak
muscles
• Debridement of plantar callosities
• Osseous mobilization
• Massage
• manipulation of the foot and ankle and strategies to
improve balance
DIVIDED INTO 2 CATEGORIES
1. non Surgical (conservative)
2. surgical
TREATMENT

38. STRETCHING EXERCISES

40. SURGICAL TREATMENT
AIMS : - to correct deformity
- to relieve pain
- to rebalance muscle forces
These aims can be achieved by :
- joint release and tendon lengthening
- tendon transfer
- osteotomy
- arthrodesis
MODIFIED JONES PROCEDURE : detach EHL , reattach to MT, IP joint fusion.
close wedge dorsal osteotomy of first metatarsal.
peroneus longus to brevis transfer ( + planter release).
Mid-foot closing wedge osteoyomy

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