Education

1. AJM Sheet: Flat Foot
Work-up
Review Questions Included

2. AJM Sheet: How to “Work-Up” a Surgical Patient
• With regard to specific surgery and the interviews, it’s always
important to “know your program”. In other words, programs
tend to have favorite procedures that they routinely do. For a
given bunion deformity, one program may primarily do Austin-
Akins, whereas other programs may never do an Akin, and still
others may always do a Lapidus in the exact same situation.
Some people may feel very strongly in favor of the lateral
release, while others may never do it for any situation. This
could even happen between two attendings at the same
program in the same room during your interview!

3. • If you give a hard, definitive answer for a procedure choice, one
attending may completely agree with you while another may think
it’s completely the wrong choice. So if you are asked what type of
procedure you would do for a given situation, be as general as
possible, but always give the reason/specific indications why you
are choosing that procedure or group of procedures. Name a
couple different similar procedures instead of sticking by your guns
with one procedure. Additionally, your interviewers may not expect
you to know for sure what procedure to choose, but they will
definitely expect you to be able to completely work-up the patient
and know which procedures are acceptable for which indications.
AJM Sheet: How to “Work-Up” a Surgical Patient

4. • The two work-ups that you should have down cold are the HAV and
flatfoot work-ups. Practice, practice, practice working through these
situations out loud, and practice, practice, practice going through the
radiographic analyses of these deformities out loud. Again, RC and I
found it helpful while studying for interviews to pick up random podiatry
textbooks and just flip through the pages, alternating our description of
the radiographs out loud.
• There are of course many, many radiographic angles that you can use to
describe during either of these work-ups, so focus the majority of your
energy on those that will have the most impact on your treatment
choice. Here’s the way that I think about these deformities. This
certainly isn’t the “right” way; it’s just the way that helped me as I first
started doing this out loud:
AJM Sheet: How to “Work-Up” a Surgical Patient

5. AJM Sheet: Flatfoot Work-up
Here I use a similar approach, but think of it in terms of planal dominance:
In which plane does the deformity present?
“Consistent with the patient’s presenting complaint we see a (mild, moderate, or severe) pes
planovalgus deformity.
In the sagittal plane I see a (decreased or increased) calcaneal inclination angle, talar declination angle,
talar-calcaneal angle, first metatarsal inclination angle, Meary’s angle, and medial column fault on the
lateral view. I would also evaluate the patient for equinus using the Silfverskiold test to determine a
sagittal plane deformity.
In the transverse plane I see a (decreased or increased) talar-calcaneal angle, cuboid abduction angle,
talar head coverage, talar-first metatarsal angle, metatarsus adductus angle on the AP view.
In the frontal plane we can see the Cyma Line is (anteriorly displaced, posteriorly displaced or normal)
on the lateral view, and that the subtalar joint alignment, ankle joint alignment and calcaneal position
are (normal or abnormal) on the long leg calcaneal axial views.”

6. AJM Sheet: Flatfoot Work-up
Now that you have defined the deformity on your own terms, you can now
suggest how to fix it using the same tools.
• “I would consider performing a (Gastroc recession, TAL, Cotton
osteotomy, medial column arthrodesis, etc.) to correct for the sagittal
plane deformity, a (Evans osteotomy, CC joint distraction arthrodesis,
etc.) to correct for the transverse plane deformity, and a (medial
calcaneal slide, STJ implant, etc.) to correct for the frontal plane
deformity.
This is a little philosophic, but radiographic angles aren’t real. They only
come into reality if you use them, so only use them as tools to your
advantage. You can use them to first define the deformity on your own
terms, and then to show that your intervention was successful.

7. Address the deformity:
• Pes planus work-up requires you to identify planal dominance.
• Pes planovalgus is mostly a tri-planar deformity so we will be
discussing potential ways to address
• Sagittal plane (DF/PF) correction,
• Frontal plane (varus/valgus) correction and
• Transverse plane correction (Abductus/Adductucs).

8. Subjective
• Wide range of presenting ages and complaints.
• Always think about posterior tibialis tendon dysfunction when someone
complains of “medial ankle pain.”
Objective
• Underlying Orthopedic Etiologies:
• Compensated forefoot varus
• Forefoot valgus
• Rearfoot valgus
• Equinus
• Compensated and uncompensated ab/adduction deformities
• Muscle imbalances (PTTD)
• Ligamentous laxity
• Tarsal coalitions

10. Physical Exam:
• Clinical presentation:
• Everted heel,
• Abduction forefoot on the rearfoot,
• Collapse of medial column,
• Too many toes sign,
• Medial bulge,
• Inc. Lat malleolar index
• Evaluate patient for equinus using Silfverskoild test to determine a
sagittal plane deformity
• Equinus – Gastroc-Soleus or Gastroc only

11. Physical Exam
• Hubscher maneuver test
• Flexible flatfoot deformity– Recreates arch
• Rigid flatfoot deformity– Does not recreate arch
• Foot functioning maximally pronated through gait cycle, posterior
equinus

12. Physical Exam:
• Gait
• Early heel off
• FF abduction
• Abductory twist
• Arch collapse
• Test STJ ROM, MTJ ROM
• Single/Double heel raises – look for calc inversion, PT tendon fxn
• RF/FF relationship
• Rigid FF valgus -- STJ supination
• Flexible FF valgus -- STJ pronation
• Rigid or flexible RF valgus
• RCSP

13. Radiographs
Practice reading x-rays in a systematic way which works for you whether it
is from proximal to distal or vice-versa. It will get you in a rhythm and also
help you to not miss any significant angles while reading under pressure
on externships.
There are basically 3 components that are involved in producing the
alignment abnormalities of symptomatic adult flatfoot:
1. Collapse of the longitudinal arch
2. Hindfoot valgus
3. Forefoot abduction

14. On DP view, the angles you should be addressing are:
1. Talo-calcaneal angle
2. Cuboid abduction angle
3. Talar head coverage
4. Talar-first metatarsal angle
5. Forefoot Abduction

15. 1. Talo-calcaneal angle
Normally ≈21°
Pronated foot: >24°
• Increased talocalcaneal
angle, indicating hindfoot
valgus in pes planus.
• Bisecting the head and neck
of the talus and a line
running parallel with the
lateral surface of the
calcaneus.
a. Pes Planus b. Rectus Foot

16. 2. Cuboid abduction angle
Normal: 0° and 5°
Flat foot- Increased
• The calcaneocuboid angle indicates deformity of the
midtarsal joint and infers subtalar joint position.
• Tangent drawn along the lateral side of the cuboid and
line tangent along the lateral border of the calcaneus
• The first cause - forefoot abduction on the rearfoot
with midtarsal pronation.
• The second cause - occurs indirectly as a result of
calcaneal eversion with excessive subtalar pronation.

17. 3. Talar Head coverage
(Talo-Navicular Articulation)
• Normal values ranging
between 75% and 80%.
• Excessive midtarsal
pronatory compensation
decrease this articulation
value below 70%.
A: Overpronated. B: Rectus/normal
Excerpt From: Christman, Robert. “Foot and Ankle Radiology.” iBooks.

18. 4. Talar-first metatarsal angle
• A line drawn through the
mid-axis of the talus should
be in line with the first
metatarsal shaft
• This angle evaluates the
degree of midfoot and
forefoot abduction.
• If it is angled medial to the
first metatarsal it indicates
pes planus.

19. On lateral view, the angles you should be addressing are:
1. Meary’s angle (Bisection of First met and talus)
2. Calcaneal inclination angle
3. Talar declination angle
4. Talo-calcaneal angle
5. First metatarsal declination angle
6. Medial column fault on the lateral view.
7. Cyma line

20. 1. Meary’s Angle (Bisection
of First met and talus)
Normal - 0 degrees
Moderate Flat Foot: 1-15 degrees
Severe Flat Foot: >15 degrees
• The long axis of the talus is angled plantar-ward
in relation to the first metatarsal, consistent with
pes planus.
• This line is used as a measurement of collapse of the
longitudinal arch.
• Collapse may occur at the TN joint, NC, or cun-met joints.
• Long axis of talus should nearly bisect navicular and 1st
metatarsal shaft

21. 2. Calcaneal inclination
angle (Aka Calcaneal Pitch)
1. Normal: 18-20
2. Pes Planus: Decreased
Bisection of the Plantar border of the
calcaneus and the horizontal reference is
the supporting surface or ground
• Sometimes a line connecting the plantar
surface of the calcaneal tubercle and the fifth
metatarsal head is used
Excerpt From: Christman, Robert. “Foot and Ankle Radiology.” iBooks.

22. 3. Talar Declination Angle
• Normal: 21 degrees
• Pes planus: Increased
• Angle between the mid-talar axis and the supporting surface
• Over-pronated foot- the talar declination line projects inferior to the
first metatarsal.

23. 4. Talo-Calcaneal Angle
(Kite’s Angle)
• Normal: 30-40 degrees.
• Pes planus: >40 degrees indicates
hindfoot valgus.
• Plantar border of the calcaneus (or a line
can be drawn bisecting the long axis of the
calcaneus).
• Through two midpoints in the talus, one at
the body and one at the neck.

24. 5. First metatarsal declination angle,
• Angle between the longitudinal axis of the first metatarsal
bone and the ground in the sagittal plane.
• Normal: 21 degrees
• Pes Planus: Decreased

25. 6. Medial column fault on the lateral view.
• The Talo-navicular, Naviculo-cuneiform, and Calcaneo-cuboid Faults.
• A fault is when a segment of the foot hyperextends, that is, shows excessive
dorsiflexion.
• Hyperextension is viewed as a collapse of a portion of the arch of the foot. No
matter which joint(s) is involved, as the forefoot is dorsiflexed, the dorsal surfaces of
the joints may appear compressed, the plantar joint space appears wider, and a sag
in the involved segment is perceived.
Excerpt From: Christman, Robert. “Foot and Ankle Radiology.” iBooks.

26. 7. Cyma Line
Anterior break of the cyma
line in Pes Planus due to
over pronation.

27. Summary
AP View
1. Increased Talo-calcaneal angle
2. Increased Cuboid abduction angle
3. Decreased Talar head coverage
4. Talar-first metatarsal
angle abnormal with medial
deviation
Lateral View
1. Increase in Meary’s angle with long axis of
talus pointing plantar-ward.
2. Decreased Calcaneal inclination angle
3. Increased Talar declination angle
4. Increased Talo-calcaneal angle
5. Decreased First metatarsal declination
angle
6. Medial column fault on the lateral view.
7. Anterior Break in Cyma line

28. Angles and their planal dominance
Transverse plane deformity:
• Kite’s angle (Lat. talo-
calcaneal angle)
• Cuboid Abduction angle
• Talonavicular Coverage
• Metatarsus Adductus (FF to
RF Adduction)
Sagittal plane deformity:
• 1st met declination
• Calcaneal Inclination Angle
• Talar declination
• Meary’s angle (talus-first metatarsal
angle on lateral view)
• Navicular cuneiform breach/medial
column fault on lateral view
• Increased talocalcaneal angle on
lateral view
Frontal plane deformity:
• Decreased height of
sustentaculum tali
• Widening of lesser tarsus (AP)
due to calc eversion
• Increased superimposition of
lesser tarsus on lateral view
• Cyma line is displaced
(anteriorly/posteriorly/inconsi
stent) on lateral view
• STJ/AJ/Calc position on
calcaneal axial view

29. Conservative Treatment:
• Orthotics
• NSAIDs
• Activity modification
• PT/stretching for equinus

30. Surgical treatment:
Procedure Selection: Can be combined or performed independently
(depending on patient’s pathology).
Now that you have defined the deformity on your own terms, you can
now suggest how to fix it using the same tools.
“I would consider performing a …. Evans or kouts etc” based on the planal
dominance of the deformity.

31. Procedures for Transverse plane deformity:
• Evans – Lateral column lengthening 1-1.5cm prox to CCJ directed anterior to
avoid the middle facet of the STJ.
• You can achieve a Tri-planar correction with Evan’s procedure.
• Transverse *primary* – adducts FF on RF
• Coronal – increasing tension on the lever arm of PL and aids in stabilization of 1st ray
and stabilization of the MLA
• Sagittal – increase tension on the spring ligament long and short plantar ligs, stabilizes
MLA, and creates pf of the FF on the RF increases the pitch of the calcaneus
• Kidner – excision of accessory navicular or prominence of navicular
tuberosity, PT tendon to underside of navicular
• Distraction CCJ arthrodesis – lengthens lateral column and fuses CCJ.

32. Procedures for Sagittal plane deformity:
• Cotton – opening dorsal wedge in medial cuneiform, corrects ff supinatus
• Lowman – TN wedge arthrodesis with TA rerouted under navicular and
sutured into spring ligament, TAL, tenodesis of medial arch w/ slip of Achilles
• Hoke – NC fusion of medial and intermediate cuneiforms to navicular with
plantar based wedge removal, TAL
• Miller – Lapidus + navicular medial cuneiform fusion, PT tendon and spring
lig advancement using osteoperiosteal flap
• Young’s Tenosuspension – Reroute TA tendon through keyhole slot in the
navicular without detaching from insertion, PT advanced under navicular
• TAL – corrects GS equinus
• Gastroc lengthening – corrects gastroc equinus
• Medial column arthrodesis

33. Procedures for Coronal plane deformity:
• STJ arthrodesis or triple arthrodesis (depending on the level of
deformity)
• Kouts – medial calcaneal slide, shifts Achilles to the supinatory side of
STJ
• Arthroeresis – sinus tarsi implant, prevents excess pronation
• Silver – lateral opening base wedge w/graft in calc
• Selakovich – opening wedge osteotomy with bone graft under sus tali
• Baker – osteotomy inferior to STJ post facet with bone graft
• Chambers – bone graft under sinus tarsi to raise the posterior STJ facet

34. Soft Tissue Procedures:
General Surgical Procedures: Indications - Keep in mind that it is very
common to do combinations of these procedures.
• FDL Tendon Transfer: FDL is sectioned as distal as possible (consider anastomosis
of stump to FHL) and either attach proximal FDL to the PT, within the PT sheath
or into the navicular under tension.
• Cobb: Split TA tendon, transfer to the PT or into the navicular
• Young’s Tenosuspension: TA rerouted through navicular
• Anastomosis of PB and PL: Removes PB as deforming force
• STJ implant (arthroeresis)
• TAL
• Gastroc recession

35. Read a flatfoot x-ray

36. Case 1

37. Case 1
This is a DP view of the right foot, skeletally
mature patient. There is an increase in
talocalcaneal and cuboid abduction angles; The
talar first-met angle is also increased and angled
medially. Talonavicular joint "congruency" is
approximately 50%. The forefoot adduction
angle is decreased.

38. Case 1
Lateral view
This is a lateral view of the right foot. I see a decrease in
calcaneal inclination angle and 1st metatarsal declination
angles. The talar declination angle and Kite’s angle is
increased. Increase in Meary’s angle with long axis of
talus pointing plantar-ward. The cyma line is "broken"
anteriorly.
Diagnosis: Pes Planus.

39. Case 2

40. Case 2
This is DP view of the right foot. Accessory
navicular type 3 noted. The is an increase in
talocalcaneal and cuboid abduction angles; The
forefoot adduction angle is decreased.
Talonavicular joint "congruency" is less than
75%.
Note: When are working up a flat foot patient, only address
pertinent angles based on the patient presentation and history. Do
not start with 1st MPJ and bunion angles.
Yes!! The patient has a severe bunion deformity BUT you are
working her up for flat foot. So stick to that.
You can vaguely address that “Bunion deformity is noted” so they
know that you know.

41. Case 2
Lateral view
This is a lateral view of the right foot. I see a decrease in
calcaneal inclination angle and 1st metatarsal
declination angles. The talar declination angle is
increased. The cyma line is "broken" anteriorly. Ankle
joint looks congruent. No significant signs of arthritis
noted.
Diagnosis: Pes planus/ Kidner foot (based upon DP
view findings).

42. Review Questions

43. How does the
calcaneal
inclination
angle change
with
pronation/supi
nation?
•It does not because it is a
structural angle

44. What is the
classification
of flatfoot?
PTTD classification
Johnson and Storm with Myerson Modification
• STAGE I -- medial pain, tenosynovitis, mild
weakness on heel raise test
• STAGE II -- medial/lateral pain, tendon
elongation, flexible pes planus, weakness on heel
raise, + too many toes
• STAGE III -- medial/lateral pain, tendon
degeneration, fixed pes planus, no inversion on
heel raise, + too many tos, STJ arthritis
• STAGE IV -- Valgus talus and ankle arthritis

45. What are
treatment
recommenda
tions per
each stage?
• Stage 1: conservative → PT, bracing,
possible immobilization, shoe gear
modification
• Stage 2: Joint Sparing procedures
and tendon transfers
• Stage 3: Rearfoot fusion procedures
• Stage 4: Rearfoot fusion procedures,
and possible addressing of ankle
valgus/arthritis

46. What is the
osteotomy
made for the
Evans
procedure? In
what
orientation/dir
ection?
•1.5 cm proximal to the CC joint,
directed anterior to avoid the
middle facet of the STJ

47. What are the
complications
of the Evans
procedure?
How does it
affect
metatarsus
adductus
angle?
•Unmasking and exaggerating
of metatarsus adduction and
an in-toe gait

48. Describe the
Young
procedure:
•Re-route the TA tendon through
a keyhole in the navicular
without disrupting the
attachment. Advancement of TP
tendon and possible TAL.

49. Describe the
Dwyer
procedure:
• Opening wedge osteotomy lateral calc
• Closing wedge-medial calc

50. What paper is
the
benchmark for
rearfoot
motion after
isolated joint
fusions? And
what was the
big picture?
• Astion, 1996, 2 degrees of motion
are preserved in STJ and CCJ after
fusion of TNJ.
• TNJ is the key articulation of
hindfoot motion.

51. What are
Glissane’s
rules for
arthrodesis?
• Complete removal of all cartilage,
fibrous tissue and other materials
preventing bone to bone contact
• Accurate and close fitting surfaces
• Optimal position of fusion
• Maintain apposition or undisturbed
until fusion complete

52. For
arthroereisis
to be effect,
what must be
reducible?
•Heel valgus and Forefoot varus
or supinatus

53. What are the
three angles
used to
evaluate
pronation vs.
supination in
the DP view?
• Talocalcaneal, cuboid abduction, and
forefoot adductus angles.

54. What are the
three angles
used to
evaluate
pronation vs.
supination in
the lateral
view?
• Talar declination,
• First metatarsal declination, and
• Calcaneal inclination angles.

55. Why is it
useful to
determine
whether the
foot is
pronated or
supinated?
• Foot position can have a profound effect on
the form of bones. One needs to be able to
predict these appearances, and not
misinterpret "odd-appearing" bone forms as
pathology.

56. What are the
best views to
order?
• At a minimum, order dorsoplantar and
lateral views.
• Lateral oblique view should be added when
considering accessory navicular;
• Include the Harris-Beath view for suspected
middle talocalcaneal coalition;
• Add the medial oblique view when
calcanonavicular bar is suspected.

57. When should
additional
imaging
studies be
ordered?
• CT can be valuable when fibrocartilaginous
middle talocalcaneal coalition is suspected
and plain films are questionable.
• MRI is useful for assessment of posterior
tibial tendon dysfunction.

58. List 2
additional
classifications
for flat foot.
Funk: Classification based on gross intra-operative
appearance
• Type I: Tendon Avulsions
• Type II: Complete midsubstance tear
• Type III: In-continuity tears
• Type IV: Tenosynovitis
Jahss or Janis Classifications: There are several
MRI classifications generally along the lines of:
• Type I: Tenosynovitis, increased tendon width, mild
longitudinal splits
• Type II: Long longitudinal splits with attenuated
tendon
• Type III: Complete rupture
• MRI is useful for assessment of posterior tibial
tendon dysfunction.

59. Additional Reading:
[Hix J, et al. Calcaneal osteotomies for the treatment of adult-acquired flatfoot. Clin Podiatr Med Surg.
2007 Oct; 24(4): 699-719.]
[Mosier-LaClair S, et al. Operative treatment of the difficult stage 2 adult acquired flatfoot deformity.
Foot Ankle Clin. 2001 Mar; 6(1): 95-119.]
[Roye DP, Raimondo RA. Surgical treatment of the child’s and adolescent’s flexible flatfoot. Clin
Podiatr Med Surg. 2000 Jul; 17(3): 515-30.]
[Toolan BC, Sangeorzan, Hansen. Complex reconstruction for the treatment of dorsolateral peritalar
subluxation of the foot. JBJS-Am. 1999 Nov; 81(11): 1545-60.]
[Weinraub GM, Heilala MA. Adult flatfoot/posterior tibial tendon dysfunction: outcomes analysis of
surgical treatment utilizing an algorithmic approach. J Foot Ankle Surg. 2001 Jan-Feb; 40(1): 54-7.]

60. References
Images:
http://uwmsk.org/footalignment/doku.php?id=pes_pl
anus
Images Excerpt From: Christman, Robert. “Foot and
Ankle Radiology.” iBooks.