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Pes planus seminar
Planovalgus foot, also known as flatfoot, is characterized by a low or absent medial longitudinal arch and hindfoot valgus. The document discusses the anatomy and development of the foot arches, causes of pediatric and adult flatfoot including posterior tibial tendon dysfunction, and treatment options ranging from orthotics to surgery. Surgical procedures discussed include calcaneal osteotomies, tendon lengthening/transfer, and arthrodesis. Complications and special flatfoot conditions like tarsal coalition and congenital vertical talus are also summarized.
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Pes planus seminar
- 1. Planovalgus foot Presenter-Dr Roshanyadav JR Orthopaedics AIIMS , New Delhi
- 2. Definition • Low orabsent normal medial longitudinal arch with a valgus hindfoot and forefoot abduction with weightbearing • Synonyms- flatfoot, fallen arches, pronation of feet • When associated with deformities of hindfoot( valgus alignment) called as pes planovalgus Carr JB, Yang S, Lather LA.Pediatric Pes Planus: AState-of-the-Art Review. Pediatrics.2016
- 4. Anatomy Of The ArchesOf Foot A) Two longitudinal arches • Medial longitudinal arch • Lateral longitudinal arch B) Transverse arch • Integrity of bony arches maintained by passive factors and dynamic supports
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- 7. Truss theory andWindlass mechanism
- 8. Medial longitudinal arch •Shape(key stone)-talus Staples-plantar ligaments, tendon of tibialis posterior • Tie beam-plantar aponeurosis, flex digitorum brevis,flexor hallucis longus,flexor hallucis brevis • Suspension arch- Tibialis anterior, posterior and medial ligaments of ankle
- 9. Lateral longitudinal Arch •Shape- key stone is cuboid • Staples-long and short plantar ligaments • Tie beam- plantar aponeurosis, abductor digitiminimi, flexor digitorum brevis, flexor digitorum longus(lateral part) • Suspension arch-peroneus longus and brevis
- 10. Transverse arch • Shape-wedgeshaped cuneiform and bases of metatarsals • Staples-deep transverse ligaments and plantar ligaments,short muscles of foot • Tie beam- tendon of peroneus longus • Suspension arch-peroneus longus and brevis
- 11. SUSPENDING THE ARCHFROM ABOVE • Medial longtitudinal arch: Tibialis anterior, Tibialis posterior, medial ligament of ankle joint • Lateral longtitudinal arch: Peroneus longus, Peroneus brevis • Transverse arch: Peroneus longus
- 12. Functions of archedfoot • 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
- 13. Development • In infantsand toddlers, the longitudinal arch is not developed and flat feet are normal. • Flatfoot in infants is actually a fatfoot as the excessive amount of fat obscures the arches • The arch develops in childhood by the age of 10 years Gould N, Moreland M,AlvarezR,etal. Developmentof the arch201child’s 4
- 14. •Flatfeet were presentin 97% of 18 months old, 54% in 3 year olds and 26% in 6 year olds and 4% at 10 years old •Boys were more likely to be flatfooted than girls(52% versus 36%) •Flatfeet were present in 62% obese , 52% overweight Pfeiffer M, Kotz R, Ledl T, et al. Prevalence of flat foot in preschool-aged children. Pediatrics 2006
- 15. A significant differencein the prevalence of flatfoot occurred between; under- weight (13.9%), normal-weight (16.1%), overweight (26.9%), and obese (30.8%)children. Conclusion: The increasing prevalence of childhood obesity is one of the most serious health challenges across the globe, and a positive correlation between increased BMI and flatfoot was present.
- 16. Causes of Flatfoot Paedatric flatfoot Adult flatfoot
- 17. Clinical features Presenting Symptoms •Parental concern • Abnormal appearance of foot • Pain • Difficulties with shoewear, walking, running
- 18. History Usually bilateral andasymptomatic, painless Ask for developmental and family history, previous medical history Age of child and any history of trauma Pain at rest,numbness,weakness,polyarticular pain,constitutional symptoms Limping,inability to bear weight
- 20. Physical examination Gait assessment Generalised musculoskeletal examination Rotationalprofiles of legs Tendoachillies tightness Generalised ligamentous laxity
- 22. Local examination Flexibility of deformity Toeraising test Jacks test Silfverskiold test
- 24. Radiology Xrays – Anteroposterior and lateralviews, Harris-Beath view Computed tomography MRI
- 25. Anteroposterior view foot • FigA- talocalcaneal(kite angle) • Fig B- talo-first metatarsal relation • Fig-C- talonavicular coverage angle
- 26. Lateral view • A-Meary’s angle • B- Calcaneal pitch(inclination) • C- Calaneus-first metatarsal angle
- 28. Cyma line • FigA- “S” shape formed by outline of calcaneocuboid and talonavicular joints- this continuous line is Cyma line • Fig-B- in flatfoot ”S” shape is displaced –anterior break in Cyma line
- 29. Lateral view • Fig A-In flatfoot, sinus tarsi of subtalar joint is not well visualized and termed as “obliterated” • Fig B- In Cavus foot, sinus tarsi is very well visualized and may be termed as “bullethole”
- 30. CT and MRI •Computed tomography is the gold standard for assessment of tarsal coalitions • Coalition type ,extent and secondary degenerative changes can be visualised • MRI- abnormalities to posterior tibial tendon, other ligaments within foot Carr JB, Yang S,Lather LA.Pediatric Pes Planus: AState-of-the-Art Review. Pediatrics. 2016
- 31. Treatment 0-7 years old: •No treatment unless very strong family history of persistent flatfeet • Counselling and reassurance of parents Carr JB, Yang S, Lather LA.Pediatric Pes Planus: AState-of-the-Art Review. Pediatrics. 2016
- 32. Conservative management • Counselling, weightcontrol and psychological support Physiotherapy- -gastrocnemius stretching , tendoachillies stretching -tibialis posterior and intrinsic muscle strengethening
- 33. Orthotics • Custom madeinserts- UCBL(University of California Laboratory) • Soft inserts - Plastazote
- 34. They concluded thereremains uncertainty about the effectiveness of foot orthosis in paediatric flexible pes planus
- 35. Surgical treatment Indications • Persistentpain and ulceration or callus under the head of the plantar flexed talus and interferes with normal activity • Rigid and painful flatfoot • To prevent progression in neuropathic(charcot joint) • Tibialis posterior dysfunction Rodriguez N, Choung DJ, Dobbs MB; Rigid pediatric pes planovalgus: surgical treatment options. Clin Podiatr Med Surg. 2010 Jan
- 36. Operative procedures Achillies tendon orgastrocnemius fascia lengethening Evans calcaneal lengethening osteotomy Mosca calcaneal lengethening osteotomy Sliding calcaneal osteotomy Plantar base closing wedge osteotomy of first cuneiform Arthrodesis
- 37. Soft tissue procedures •TA lengethening- percutaneous TA lengethening - Z lengthening • Gastrocnemius recession
- 38. Tendoachillies lengethening isa safe procedure when used in conjunction of hindfoot fusion procedures for flatfoot deformities
- 39. Evans calcaneal osteotomy • Lengtheningof lateral column of the foot by inserting bone graft and calcaneocuboid fusion
- 41. Cotton medial cuneiformosteotomy
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- 43.
- 44. • Usually doneafter the age of 12 • Triple arthrodesis tend to have a high (50%) failure rate in children under 10 years of age • Contraindicated in young children (less than 10-12 yrs) because the procedure limits foot growth
- 45. Triple Arthrodesis Joints fusedare: • Subtalar joint • Calcaneo cuboid joint • Talo navicular joint
- 46.
- 47. Complications of Surgery •Nonunion • Degenerative joint disease • Avascular necrosis • Lateral instability • Stiff foot
- 48. Posterior tibial tendondysfunction • The most common cause of acquired adult flatfoot is posterior tibial tendon dysfunction • Anatomy
- 49. Etiology • Spontaneous rupture •Trauma • Inflammatory disorders, collagen disorders • Presence of accessory navicular bone
- 50. Examination • Inspection- - flatfoot, swelling along PTT, fullness around medial aspect of ankle,lateral skin wrinkling -hindfoot valgus, too many toes sign • Rom- ankle, subtalar, midfoot • Specific tests-heel rise test
- 52. Treatment • Stage 1-Conservative management and tenosynovectomy • Stage 2- Flexor digitorum longus tendon transfer combined with medial displacement calcaneal osteotomy • Advanced stages- subtalar arthrodesis , triple arthrodesis
- 53. Types Flexible –on weightbearing arch disappears and on non weight bearing it reappears Rigid – acceptable medial longitudinal arch is not seen even on non weight bearing with reduced or absent motion in midfoot,hindfoot
- 54. Causes of rigidflatfoot • Tarsal coalition • Congenital vertical talus • Peroneal spastic foot • Post traumatic
- 55. Tarsal Coalition Anatomic classification •Calcaneonavicular (most common) • Talocalcaneal Pathoanatomic classification • Fibrous (syndesmosis) • Cartilaginous(synchondrosis) • Osseous(synostosis)
- 56. Examination • Inspection- hindfootvalgus, forefoot abduction , pes planus • Range of motion- limited subtalar motion, heelcord contractures, arch doesnot reconstitute on toe standing
- 57. •Radiography- Ap,lateral 45 degreesinternal oblique view, harris beath view •CT scan , MRI
- 58. Calcaneal- navicular coalition • Calcanealnavicular coalition– anteater nose sign
- 59. Talocalcaneal coalition- Csign , talar beaking
- 60. Accessory navicular bone •It is a normal variant located in posteromedial aspect of foot, proximal to navicular bone • Often incidental, most patients are asymptomatic/ medial arch pain • Examination-swelling, tenderness of medial aspect of foot
- 61. Radiography • Special view- 45 degree external oblique • Antero-Posterior view and lateral weight bearing views of the foot should be taken to evaluate other deformities
- 62. Radiographic classification • Type 1-Sesamoid bone in the substance of tibialis posterior tendon • Type 2- Separate accessory bone attached to native navicular via synchrondosis • Type 3- Complete bony enlargement
- 63. Treatment Nonoperative • Activity restriction, shoe modification, analgesics • Cast immobilization Operative • Excision of accessory navicular (kidner procedure)
- 64.
- 65. Congenital vertical talus •Irreducible dorsal dislocation of navicular on the talus producing rigid flatfoot deformity at birth, 50% bilateral • 50% associated with neuromuscular disease or chromosomal aberrations- • Myelomeningocele • Arthrogryposis • Diastematomyelia • Cerebral palsy, spinal muscular dystrophy
- 67. Management • Nonoperative- Serialmanipulation and casting • Operative -talonavicular reduction and pinning -minimally invasive correction -talectomy -triple arthrodesis
- 69. Summary • Hypermobile flatfootis a normal variant of foot structure and doesnot require prophylactic treatment • Nonoperative management in adolescents is generally successful • Causes of rigid flatfoot should be ruled out with proper investigation • Surgical correction should emphasize on joint sparing procedure
- 70.
- 71. Z shaped(serpentine) deformity offoot is found in a)congenital vertical talus b)calcaneo-navicular coalition c)pes cavus d) skew foot
- 72. What is thenormal value of Meary’s angle? a) 10-15 degrees b) zero degree c) 30-45 degrees d) 15-30 degrees