Pes cavus and pes planus are foot deformities characterized by high and low arches, respectively. Pes cavus, or a high arched foot, can be congenital or acquired and results in clawing of the toes. Pes planus, or a flat foot, is caused by the collapse of the medial longitudinal arch. Both conditions can cause foot, ankle, and leg pain and abnormal shoe wear. Treatment involves orthotics, physical therapy, and sometimes surgery to correct muscle imbalances and bony deformities.

1. Pes Cavus and Pes Planus
Moderator:PROF.DR.K.PRAKASAM
M.S.Ortho,D.Ortho,DSc(HON)
Director&HOD
Presentor:Dr.Thouseef A Majeed

2. ANATOMY OF THE ARCHES OF FOOT
A) Two longitudinal arches
– Medial longitudinal arch
– Lateral longitudinal arch
B) Transverse arch
• Anterior transverse arch
• Posterior transverse arch

3. USE OF THE ARCHED FOOT
 Supports body weight in upright posture
 Acts as a lever to propel the body forwards in walking,
running and jumping
 Acts as a shock absorber
 Concavity of the arches protects the soft tissues of the sole
against pressure

4. Medial longitudinal arch
• Higher than lateral
• Composed of – Calcaneous
- Talus
- Navicular
- 3 cuneiform
- 3 metatarsals
• Talar head is key stone of this arch

5. • Tibialis anterior attached to – 1st metatarsal,medial cuneiform –
strength for this arch.
• Peroneus longus tendon – pass laterally to this arch providing
support

6. Lateral longitudinal Arch
• Flatter than medial longitudinal arch.
• Rests on the ground during standing.
• It is made up of – calcaneous, cuboid, 2 lateral
metatarsals.

7. Transverse arch
• Runs from side to side
• It is formed by – cuboid,
cuneiforms, bases of
metatarsals
• Medial and lateral parts
of longitudinal arch act as
pillars
• Tendons of fibularis
longus and tibialis
posterior

8. Integrity of bony arches
• Maintained by passive factors and dynamic
supports

9. Passive factors
• Shape of the united bones
• Four successive layers of fibrous
tissue – bowstring the longitudinal
arch
– Plantar aponeurosis
– Long plantar ligament
– Plantar calcaneocuboid (short
plantar) ligament
– Plantar calcaneonavicular
(spring) ligament

10. Dynamic supports
• Active bracing action of intrinsic muscles of foot
• Active and tonic contraction of muscles with long
tendons extending in to foot
– Flexor hallusis and digitorum longus – longitudinal arch
– Fibularis longus and tibialis posterior – transverse arch
• Plantar ligaments and plantar aponeurosis bear
greatest stress and important in maintaining arches

11. MECHANISM OF ARCH SUPPORT
SHAPE OF BONES
• Bones are wedge-shaped with the thin edge lying inferiorly
• This applies particularly to the bone occupying the center of
the arch“keystone”

12. MECHANISM OF ARCH SUPPORT
SUSPENDING THE ARCH FROM ABOVE
• Medial longtitudinal arch: Tibialis anterior, Tibialis
posterior, medial ligament of ankle joint
• Lateral longtitudinal arch: Peroneus longus, Peroneus
brevis
• Transverse arch: Peroneus longus

13. MECHANISM OF ARCH SUPPORT
SUSPENDING THE ARCH FROM ABOVE

14. PES CAVUS

15. Synonyms for Cavus Foot
• Schaffer Foot
• Lotus Flower Foot
• Bolt Foot
• Claw Foot
• Vault Foot
• Hollow Foot
• Anterior Equinus
• Pes Cavo Varus
• Contracted Foot
• Talipes (Pes)
Arcuatus
• Talipes Plantaris

16. Defenition
• Cavus is an acquired or congenital deformity
of the foot ,characterized by excessive high
longitudinal plantar arch combined with
clawing of the toes .

17. Etiology
Neurological Causes
• Charcot Marie Tooth disease
• Friedrich’s Ataxia
• Roussy-Levy syndrome
• Poliomyelitis
• Cerebral Palsy

18. Congenital
– Spina Bifida
– Talipes Equinovarus
– Myelodysplasia
– Clubfoot
Iatrogenic
– Post surgery or trauma
– Peroneal nerve injury

19. Etiology
Infection
– Syphillis
– Poliomyelitis
Idiopathic
– Most common

20. Development of the deformity
• The intrinsic musculature
normally flexes the
metatarsophalyngeal joint
and extends the
interphalyngeal joint.

21. • When the long flexor contracts on the straight digit it slings
up the heads of the metatarsals and prevents the drop of the
forefoot on the hind foot
• In the absence of lumbricals ,the long flexor pulls the toes
into flexion and no longer supports the metatarsal head.

22. • So the forefoot drops and the lax structures in the sole
contracts and forms claw foot.
• Dropping of fore foot on the hind foot followed by a
contracture of the plantar fascia and clawing of the
toes

23. CLINICAL FEATURES
• High arch.
• Hyper extension of toes at
metatarso-phalyngeal joint
• Hyper flexion at the inter-
phalyngeal joints.
• Pronation and adduction of
the fore foot .

24. • Lengthened lateral border of foot
and shortened medal border.
• Callosities beneath the metatarsal
heads
• A bony dorsum of mid-foot with
wrinkled skin folds on the medial
plantar aspect

25. Radiographic findings –pes cavus
Standing weight bearing Antero –posterior and Lateral views
X Rays taken to
• Demonstrate the apex of the deformity
• Talo calcaneal ankle
• Calcaneal pitch
• Degree of plantar flexion of the great toe
• Asess the contribution of cavus by hind foot,midfoot and
fore foot

26. DEGREES OF PES CAVUS
• 5 degrees
First degree pes cavus
• Child is clumsy with repeated falls
• Foot appears normal
• Deformity appears when foot is relaxed
• Child catches his toes against low objects such as edges of
carpet.
• Mild extensor weakness

27. Treatment of first degree pes cavus
• Daily manipulation –supinating fore foot and everting heel
• Anterior arch bar in shoes
• If not corrected then Girdle stone tendon transfer
operation.

28. • Through an incision on each toe
extending distally from metatarso-
phalyngeal joint .
• Long and short toe flexors are brought
to lateral aspect of proximal phalynx
and sutured to the extensor expansion.

29. Second degree pes cavus
• Flexion of the fore foot
• Plantar fascia is felt to be tense and contracted
• Clawing of great toe .
• Great toe clawing can be corrected by upward pressure on
the ball of great toe.

30. Treatment of second degree Pes cavus
• A shoe fitted with a metatarsal bar may give temporary
relief.
• Stiendlers Procedure : Plantar fascia release
• Jones Procedure:The Extensor hallucis longus tendon is
divided at its insertion and passed though the neck of first
metatarsal + Interphalyngeal joint fusion.

32. Third degree pes cavus
• The arches of foot is markedly raised.
• All toes are clawed .
• Tendocalcaneus may begin to appear contracted.
• Painfull callosities are seen.
• Deformities are rigid and cannot be corrected by finger
pressure under Ist metatarsal head

33. Treatment of third degree Pes cavus
• Stiendlers procedure +Muscle sliding
operation.
• Japas ‘ V‘osteotomy of tarsus : Apex of V is
proximal and highest point of cavus
• Dwayers Calcaneal Ostetomy

35. Fourth degree pes cavus
• In addition to cavus and claw toes
• Adduction at tarsometatarsal joints resulting in varus
deformity.
• Rigid and painful foot
• Walking becomes painful and difficult.

36. Fifth degree-pes cavus
• Seen on paralytic conditions.(poliomyelitis)
• Whole foot is contracted into rigid equino varus with high
arch.
• Tender callosities.
• The patient is very disabled .

37. Treatment of fourth and fifth degree Pes cavus
• Dunns triple arthrodesis
• Lambrinudis arthrodesis
(triple arthrodesis :subtalar+calcneo cuboid +talo
navicular joint fusion)
• Cols Anterior tarsal wedge osteotomy

39. PES-PLANUS

40. Synonyms
• Pes planovalgus
• Flat feet
• Fallen arches
• Pronation of feet

41. Definition
• Absence of normal medial longitudinal arch
• Instep of the foot collapses and comes in
contact with the ground.
• In some individuals, this arch never develops

42. Other abnormalities
• Heel valgus
• Mild subluxation of subtalar joint(talus tilts medially
and plantarwards)
• Eversion of the calcaneus at the subtalar joint
• Lateral angulation of midtarsal joints (Talo Calcaneal
,Calcaneo Cuboid)
• Supination of forefeet

43. • Flat feet are a common condition.
• In infants and toddlers, the longitudinal arch is not
developed and flat feet are normal.
• The arch develops in childhood
• By adulthood (12-13yrs), most people have
developed normal arches

44. Types
 Flexible Can be
 Rigid painless
Painful

45. Types
• Flexible –on weight bearing it disappears and
on non weight bearing it reappears
• Rigid – acceptable medial longitudinal arch
does not seen even on non weight bearing
• Flexible, painless is most common

46. Etiology
Flexible
Developmental – the most common
Hypermobile (ligamentous hyperlaxity; Ehlers-Donlos, Marfans)
Neurogenic( rare and usually cause the reverse-Pes Cavus)
Rigid
 Congenital (Tarsal coalition,Vertical talus)
Aquired )inflammatory)

47. SYMPTOMS
Deformity
• Foot pain ,ankle pain, leg pain
• Heel tilts away from the midline of the body more than
usual
• Abnormal shoe wear

48. FLAT FEET CAN produce
• Tendonitis. posterior tibial tendon and it can either fail,
rupture, stretch or just hurt. This condition is called
POSTERIOR TIBIAL DYSFUNCTION (PTD OR TPD) .
• Arthritis.
• Plantar fasciitis
• Bunions & Hammertoes
• Corns and callosities

49. Radiography
• Asymptomatic flatfoot radiological evaluation unnecessary
• First Antero posterior and Lateral views of the foot should
be taken to evaluate severity of deformity
• Antero-posterior ankle to rule out valgus at the distal end of
tibia
• Special view - 45 degree eversion oblique for accessory
navicular bone

50. Radiography
• AP standing view is to asses heel valgus , Talocalcaneal
angle more than 35 degree is associated with incresed heel
valgus
• CT scan accurately defines anatomy of subtalar joint ,
allows surgical plannig if it is involved.

51. Meary’s Angle
• Most common angle to indicate
flat foot
• Intersects at apex of the
deformity
• Meary’s angle - between long
axis of talus and long axis of
first metatarsal on a standing
lateral X ray

52.  Normal Meary's angle:long axis
of the talus should bisect the
navicular and first metatarsal
0 degrees – normal
0 – 15 degrees – mild
15 – 40 degrees – moderate
> 40 degrees – severe
The long axis of the talus is angled plantarward in relation to
the first metatarsal, consistent with pes planus

53. Treatment
0-3 years old:
 No treatment unless very strong family hx of persistent
flatfeet
 Orthotic shoes with thomas heels ,medial heel wedges and
navicular pads
 Convince the parents.

54. Treatment
3-9 years
• Conservative management
• No surgery
• Custom orthosis inserted with leather ,cork,
propylene .

55. Treatment
• 10-14 yrs
• No symptom- No treatment
• Symptomatic – conservative management
initially
• Surgical

56. Surgical treatment
Indications
1.pain
2.failure to respond to orthotic control
3.Ulceration or callus under the head of the plantiflexed talus
4.Excessive shoe wear

57. Surgical treatment
• The surgeon , patient, and parents must be willing to
exchange loss of eversion and inversion of the foot
for relief of pain and disability .

58. Surgical treatment
• Arthrodesis for relieving painful flat foot have been
most successful when the subtalar joint is involved .
• Although midtarsal arthtrodesis without inclusion of
the subtalar joint has gained popularity

59. Surgeries
• Durham flatfoot plasty
• Posterior calcaneal displacement osteotomy
• Anterior calcaneal lengthening – distraction
wedge osteotomy
• Triple atrhrodesis (triplane)

60. Durham plasty for pes planus
A, Incision.
B, Elevation of posterior tibial
tendon.
C, Elevation of osteo-periosteal
flap from proximal to distal.
D, Arthrodesis of navicular–first
cuneiform joint.
E, Extent of arthrodesis resection
through midfoot.
F, Internal fixation of navicular–
first cuneiform joint.

61. •
pull the posterior tibial tendon taut
into its prepared bed on the plantar
surface of the waist of the
navicular, and tie the suture
dorsally

62. Calcaneal osteotomy (Dilwyn-
Evana,Mosca)
• Lengthening of lateral
column of the foot by
inserting a tibial bone graft
and calcaneocuboidal
fusion

63. Posterior calcaneal displacement
osteotomy(koutsgiannis)
• Symptomatic patients with excessive heel valgus , a
calcaneal osteotomy is intended to displace the
posterior part of the calcaneum medially , to restore
normal Weight bearing alignment

64. Triple Arthrodesis
Joints fused are:
• Subtalar joint
• Calcaneo cuboid joint
• Talo navicular joint

65. AGE
• Usually done after the age of 12
• Triple arthrodesis tend to have a high (50%) failure rate in
children under 10 years of age;
• contra-indicated in young children (less than 10-12 yrs)
because the procedure limits foot growth

66. Complications
• Nonunion
• Degenerative joint disease
• Avascular necrosis
• Lateral instability
• Stiff foot

67. Accessory navicular bone
• It is a most common accessory bone in the foot
• Listed as a cause of flat foot

68. Pathoanatomy
• Abnormal insertion of Tibialis Posterior into
accessory navicular bone believe to cause the flat
foot

69. Clinical presntation
• Often incidental, many patients are asymptomatic
• Pain
• Prominence of medial aspect of foot
• On attempted inversion of the foot against resistance
, Tibialis posterior tendon is inserted into the bump
and this maneuver produces pain

70. Radiography
• Special view - 45 degree eversion oblique for
accessory navicular bone
• Antero-Posterior view and Lateral weight bearing
views of the foot should be taken to evaluate other
deformities

72. Radiological types
• TypeI–Small ossicle in the substance of Tibialis Posterior
tendon (os tibiale externum or naviculam secondorium )
• Type II –Triangular frangment larger than type I connected
to navicular bone by a cartilaginous synchondrosis
• Type III – Cornuate navicular resulting from fusion of the
accessory navicular with main body of navicular

73. Treatment
INITIAL TREATMENT –
Conservative- stretcing shoes, avoiding activity
that irritates foot
SURGICAL-
Kidners procedure

74. Kidners procedure
• Excision of accessory navicular bone and rerouting of
Tibialis Posterior tendon into a more plantar position
• Parents should be informed before surgery that pain
may not be alleviated completely

75. “Our feet are no more alike than our
faces”
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