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4 a adult acquired flat foot - Derek Park
- 2. Introduction • Low arched foot is variable in population • Flatfoot – abnormal loss of arch with pain
- 3. Causes • Posterior Tibial Tendon Dysfunction (PTT) • Achilles/Gastroc contracture – 2º PTT dysfunction • Inflammatory arthritis • 1º midfoot arthritis of fracture non-union • Calcaneus or Cuboid fracture malunion • Peroneal Muscle spasm • Neuropathic deformity • Coronal plane angulation
- 4. Deformity • Flatfoot is the end point of an medial collapsed arch. • Hindfoot → Valgus • Forefoot → Supinates • Sagittal Plane → longitudinal arch collapses • Axial Plane → Forefoot abducts • Lateral column is shortened • 3D – dorsolateral peritalar subluxation
- 5. Deformity
- 6. Arches of the foot • Medial Longitudinal Arch • Lesser Longitudinal Arch • Transverse Arch
- 7. Arch Supports • Static – Spring ligament – Superficial deltoid – Plantar fascia • Dynamic – PTT – Ext/In toe flexors – Achilles
- 8. PTT during Gait • Heel contact – shock absorber • Midstance – initiates inversion of the hindfoot • Propulsive phase – Vector of Achilles shifts medially secures hindfoot
- 9. Clinically • Foot Pain (medial, lateral), Knee, Hip • Swelling – medial along PTT • Standing, walking aggravate • Abnormal gait (push off) • Progressive flat foot
- 10. Physical Examination • Visualise legs from knee down - Arch height compared with other side, too many toes sign • Look at heel alignment • Palpate along PTT • Single heel raise • Test Inversion/Eversion • Gastroc-soleus – Contractures • Subtalar joint for mobilty • Fixed vs Rigid
- 11. RADIOGRAPHS
- 12. Lateral Xray Lateral talar-1st MT (Meary angle), >4º Flatfoot 17-32° is normal
- 13. Talo navicular coverage angle > 7 degrees indicates lateral subluxation
- 14. AP Look for talar aligment
- 15. Other Imaging • USS – stage 1 of PTT dysfunction correlates well with surgical findings • MRI – More detailed
- 16. PTT - Anatomy • Posterior Tibia → 1º Navicular Tub, 2º 2-4 MT, Cuniforms, Cuboid • Also attaches to deep fasica, peroneal tendons and long and short flexors • Avascular zone in tendon behind medial malleolus
- 17. Staging
- 18. Treatment • Aim – pain free and normal biomechanics • Depend on underlying condition • Stage of disease
- 19. TREATMENT • Non-operative: Tibialis posterior eccentric strengthening exercises, NSAIDs, orthotics • Operative: depending on stage of disease • Early stages with no fixed deformity = orthotics & tendon transfer and heel osteotomy • Later stages with fixed deformity = triple fusion or pantalar fusion
- 20. Non-operative • Anti-inflammatory to control pain • Rest in a short leg cast • Bracing and orthotics – Flexible, Medial supports, AFO, UCBL – Rigid, accommodative devices, custom moulded AFO
- 21. Surgical Principles • If PTT is source of pain should be addressed with repair and augmentation • Pain from osseous impingement, arch alignment must be improved to decompress painful area • Arthritis pain – joint fusion • Consider TA lengthening
- 22. Stage 1 PTT dysfunction • Repair and augment tendon • Consider calcaneal sliding osteotomy • Medial Approach • Diseased tendon maybe excised • FHL/FDL/PB is as an augment
- 23. Collapsed Arch, no degeneration • Aim is to realign the hind foot without sacrificing the hind foot joints • Augment PTT • Medial Calcaneal osteotomy • Medial column stabilisation • Lateral column lengthening
- 24. EARLY STAGES
- 25. Medial column stabilisation • Medial Collapse at met-cun, NC joint • Collapse can be seen on lateral films • Realignment can result in good correction of the arch • Often combined with calcaneal osteotomy
- 26. Lateral column lengthening • Hindfoot valgus drive the calcaneus posteriorly • Lengthening drives the foot around the talus through the TNJ • Osteotomy of ant process of calcaneus or through the cal-cub joint
- 27. Lateral column lengthening • Improves talar head coverage, reduces forefoot abduction, diminishes hindfoot valgus • Peroneal lever arm is lengthened, planter fascia is lengthened, TA shifts medially
- 28. Forefoot Supination • Collapse of hindfoot leads to compensatory forefoot supination • Elevated first ray after hindfoot correction • First metatarsocuneiform planter flexion arthrodesis
- 30. Advanced Flatfoot (Stage 3) • Triple arthrodesis is gold standard for rigid flatfoot (Subtalar, TN, CC) • Performed with realignment • Address the forefoot supination
- 32. Ankle Valgus (Stage 4) • Pantalar fusion • 2 stage procedure – Triple fusion – Ankle replacement
Editor's Notes
- PTT dysfunnction – most common cause Inflammatory Arth – subluxtion of hindfoot joints and PTT dysfunciton Peroneal Muscle spasm – in neuromuscluar disease Coronal plane angulation – knee, tibia, ankle – drive foot into valgus
- Increase in peak pressures in the subtalar joint Sagittal plane – TN, NC, 1st TMT dorsolateral peritalar subluxation – subluxtion occurs around the talus but joints maybe involved Disease is progressive
- Medial Longitudinal Arch - 1st MT, Medial Cun, Nav, Talus Lesser Longitudinal Arch – 4/5 MT, Cub, Lat Cal Transverse Arch – spans midfoot 2/3 mt bases keystones
- Spring Ligament - Sustentaculum tali > medial navicular Cradles talar head Superfical deltiod – MM – inserts into SMCN, acts a check rein for the entire complex PTT – powerful planter flexor and invertor, locks the transverse tarsal joimts -- TN, cal-cub - acts as an arch support during gait and loading situations - PTT fires just before heel rise portion of gait, creates a rigid medial column for push off EXT/IN flex- secondary role Achilles – vector in medial in toe off and supports the arch Achilles vector in lateral in flat foot Contracture can exacerbate flat foot Achilles tighness may preceed PTT symptyoms.
- Foot – medial PTT of deltoid - Lateral due to impingement of talar head or calcaneum on fibula - Arthritis in foot Knee – valgus stress can casue medial joint OA
- Less than ten single heel raises incate PTT weakness
- Loss of aligment between the first metatarsal and the midfoot Decreased calcaneal pitch = pes planus. Increased pitch = pes cavus
- Johnson & Strom Stage 1: Tendon inflammed, functional Stage 2: Tendon no longer functioning Foot deformity flexible Stage 3: Tendon no longer functioning Foot deformity not correctable Stage 4: Stage 3 + involvement of ankle joint
- Rest in short leg cast for ptt tenfopathy FLEX Bracing and orthotics – heel valgus Medial arch supports with medial heel wedge medial colunmn post AFO or UCBL(control forefoot abduction) RIGID Support the foot for pain control
- Repair and augment tendon Consider calcaneal sliding osteotomy – move medial to axis of achilles of subtalar joint to help support the PTT repair Medial approch – rentinaculum, tendo sheath and tendon are inspected.
- Soft tissue and bony procedures Med Can Ost – TA acts as invertor of the foot
- Collapse leads to 2ary Flat foot
- Non-union is higher in cal-cub os Increases calc pitch and shouldn’t be used in pateints were the pitch was normal at the start
- Some patients may require a combination of the two