PES PLANUS AND PES

VALGUS
PRESENTER : DR. BIJAY MEHTA
MODERATOR : DR. GYANENDRA VIKRAM SHAH
CONTENTS
•INTRODUCTION
•ANATOMY OF THE ARCHES OF FOOT
•COMMON CAUSES
• FLEXIBLE FLAT FOOT
• CONGENITAL VERTICAL TALUS
• TARSAL COALITION
• ACCESSORY NAVICULAR
• POSTERIOR TIBIAL TENDON DISORDER
•SUMMARY
FLAT FOOT : INTRODUCTION
•Condition in which the medial arch of the foot is diminished or
absent, allowing the entire sole to touch the ground.

Can be
• Asymptomatic/Symptomatic
• Flexible/Rigid/Compensatory
INCIDENCE
• 23 % of adult population.
• Of this ,approximately two thirds have a flexible flatfoot.
• Approximately one fourth of flatfeet exhibit a contracture of the
triceps surae associated with an otherwise typical hypermobile
flatfoot
• The remainder of flatfeet are characterized by more rigidity of the
subtalar joint, typically seen with tarsal coalitions.
CLINICAL FEATURES
• Medial arch of the foot is depressed
(REPRODUCIBLE/NON REPRODUCIBLE)
• Heel bone, when viewed from the rear is
everted or in valgus
• Forefoot is abducted relative to the hindfoot

• “Too many toes sign”

 ARCHES OF FOOT
• The springboards and shock absorbers of foot.

• There are three main arches of foot :

• Medial longitudinal arch
• Lateral longitudinal arch
• Transverse arch
MEDIAL LONGITUDINAL ARCH
• Arch –Why??
• Segmented structure supports weight best if built in
form of arch
• Highest and most flexible arch
• Acts as shock absorber
• Helps in propulsion of the foot while walking
 SUPPORTS OF MLA
• The key stone is the talus
• The staples are plantar ligaments,
tendon of tibialis posterior
• The tie beam is made by plantar
aponeurosis, flexor dig. Brevis,
abductor hallucis, flexor hallucis
longus, flexor dig. Longus, flexor
hallucis brevis
• Ant pillar : 3 metatarsal heads
•Post pillar : medial calcaneal
tubercle
 FLAT FOOT : CAUSES
PEDIATRIC ADOLESCENT ADULT

• FLEXIBLE • TARSAL • POSTERIOR TIBIAL

FLATFOOT COALITION TENDON
• CONGENITAL • ACCESSORY INSUFFICENCY
VERTICAL TALUS NAVICULAR • POST
TRAUMATIC
• ARTHRITIC
 FLEXIBLE FLATFOOT
• Common childhood complain

• Arch is usually obscured in an infant’s foot because of subcutaneous fat.

• Usually disappears between 4 to 10 years when longitudinal arch develops.

• “usual in infants, common in children, and within the normal range in

adults”- Staheli and Colleagues
 FLEXIBLE FLATFOOT
• May be associated with ligamentous laxity- look for Beighton score

• Needs to be differentiated from CALCANEOVAVALGUS

• Calcaneovalgus

• Rigid flatfoot

• Incidence-30%

• Packaging disorder
 CLINICAL FEATURES
• Painless most of the times.
• Usually noticed by parents, grandparents or assistants in
the shoe shop
• On Inspection:
• excessive eversion during weight bearing,
• the forefoot is abducted, with a midfoot sag with
lowering of the longitudinal arch
• medial column appears longer than the lateral
column
• On Palpation:
• talar head and navicular tuberosity appear to be in
contact with the floor
 CLINICAL FEATURES
• Movement :
• may have increased mobility of ankle or subtalar joint
• Tests :
• Tip toe test : Inversion of the heels and arch reconstitution
during toe standing
• Jack’s Test/Hubscher’s Test : Dorsiflexing the great toe
restores the arch
IMAGING
• Usually not required
• Done to rule out causes of the deformity
other than idiopathy
• BUT ONE CAN VISUALISE FOLLOWING
PARAMETERS WITH ITS AID:
• lateral talus–first metatarsal angle, or
Meary angle
• location of the sag—talonavicular or
naviculocuneiform joint
• degree of plantar flexion of the talus
FLAT FOOT : TREATMENT
• SURGERY VS CONSERVATIVE
• Indications for surgery
• Intractable symptoms unresponsive to shoe or orthotic modifications
• In individuals who are unable to modify the activities that produce pain
 FLEXIBLE FLATFOOT : TREATMENT
• Conservative Treatment
• No treatment required in an asymptomatic pediatric
patient.
• Education and reassurance are the mainstays.
• If an Achilles tendon contracture is
present- stretching exercises-both active
and passive
Role of orthoses
• Traditionally used in all patients

• But there is no scientific

evidence that orthoses and
medial arch supports are
efficacious.

• BUT…in cases of medial arch

pain and fatigue, as well as
cramping at night the orthoses
may be helpful.
SURGICAL TREATMENT : OPTIONS
• Arthroereisis- limits the amount of valgus motion
in the subtalar joint by using an interposition peg
• Lateral column lengthening
• Heel cord lengthening
• Imbrication of talonaviculocuneiform complex
• Subtalar fusion - only as salvage procedure.
• Triple arthrodesis
Lateral column lengthening
Talonaviculocuneiform imbrication
CONGENITAL VERTICAL TALUS
• A cause of rigid pes planus
• Characterized by a fixed dorsal dislocation of the
talonavicular joint in conjunction with rigid
hindfoot equinus

• Rocker bottom deformity

• Aka congenital convex pes valgus, teratologic
dorsolateral dislocation of the
talocalcaneonavicular joint

• 1 in 10000 live births

 ETIOLOGY
• Exact etiology unknown
• Likely causes
• Abnormal variation in muscle fibre size
• Congenital vascular abnormalities
• Arrest in fetal development of foot at 7-12 weeks POG
• Autosomal dominant pattern of inheritance
• Gene mutations (HOXD10 )
 ASSOCIATIONS Associations

• 60% associated with other

congenital anamolies

Neurological
Genetic
Discorders

spinal muscular atrophy,

Myelomeningocele-10% neurofibromatosis,
Trisomy 13,15 ,18
Arthrogryposis-11% congenital dislocation of
the hip
PATHOANATOMY

• Hindfoot in equinus
• Calcaneum and talus in equinus
• Contracture of Achilles tendon
• Forefoot in Dorsiflexion
• Dorsal dislocation of talovicular joint
• Navicular lies onto neck of talus
• Contracture of foot dorsiflexors
• In Total – Convex Platar Deformity
 PATHOANATO
MY
LIGAMENTOUS CHANGES:
• CONTRACTED ONES: tibionavicular portion of the superficial deltoid, bifurcated
ligament, calcaneofibular ligament, and the interosseous talocalcaneal ligaments
• ATTENUATED ONES: spring ligament

TENDONS AND MUSCLE CHANGES:

• CONTRACTURES OF : tibialis anterior, long toe extensors, peroneus brevis, and triceps
surae
• Posterior tibial and peroneal tendons may be displaced anteriorly so that
they act as dorsiflexors rather than plantar flexors.
 CLINICAL
FEATURES
ON INSPECTION:
• a rocker bottom foot, the apex of which is at the talar head
• callosities may be seen
• hindfoot foot is everted into a valgus
• forefoot is abducted and dorsiflexed

ON PALPATION:
• a contracted achilles tendon
• peroneal and anterior tibialis tendons are taut
• navicular is palpable as it lies on the talar neck

ON MOVEMENT: passive correction of deformity is impossible

 IMAGING:
XRAY
• LATERAL PROJECTION:
• Neutral
• Maximum Dorsiflexion
• Maximum Plantarflexion
• Differentiate from Oblique Talus- Talus aligns with
1st metatarsal in maximum plantarflexion
 CVT FOOT
NORMAL FOOT
 TREATMENT
EARLIER BELIEF :
• Major reconstructive surgery was necessary to correct the deformities
• But resulted in substantial complications- STIFFNESS
RECENT BELIEF : Serial casting (described by Dobb)
• to stretch the contracted dorsal and lateral soft tissues
• gradually reduce the talonavicular joint followed by
• Minimally invasive procedures for final correction.
Reverse Ponsetti Casting
• Serial Casting
• forefoot is first stretched into plantar flexion and inversion by applying distal traction to
the metatarsals
• upward push on the calcaneus and a downward pull on the heel may stretch
equinus deformity
PRINCIPLES OF SURGERY:

• Staged Surgery
• FIRST STAGE: reduction of the navicular on the talus by release of the anterior
tibialis tendon and the tibionavicular and talonavicular ligaments and capsule.
• SECOND STAGE : lengthening of the toe extensors and peroneals to allow reduction
of the forefoot with calcaneocuboid reduction
• THIRD STAGE: release of the equinus contracture, lengthening of the Achilles
tendon, and division of the ankle and subtalar joint capsules.
• FOURTH STAGE : transfer of the anterior tibialis tendon to the talus to
dynamically stabilize the correction
 TARSAL COALITION
• An abnormal connection between two or more bones of the foot
• Produce pain and limitation of foot motion.

• Incidence varies from 0.03% to 1.0%.

• 50 to 60% of tarsal coalitions are bilateral.

• Tarsal coalition, rigid pes planus, and peroneal muscle spasm - components of
peroneal spastic pes planus.
TYPES OF TARSAL
COALITIONS
• Calcaneonavicular: most common form but less symptomatic
• Talocalcaneal: more symptomatic form
• Other rare forms : calcaneocuboid, naviculocuboid, naviculocuneiform, or
massive tarsal coalition
• Etiology: Failure of normal segmentation of fetal tarsal
• Autosomal dominant inheritance
 ASSOCIATIO
NS
• Cavovarus deformity and talipes equinovarus

• Fibular hemimelia: Asymptomatic Tarsal coalitions

• Nievergelt-pearlman Syndrome: massive tarsal and carpal
coalitions
• Apert Syndrome
SYNDROMIC
COALITIONS
CLINICAL
FEATURES
Symptoms :
• Usually become symptomatic around12-16 yrs of age
• Pain-
• often over the tarsal sinus, beneath the medial malleolus, along the arch
of the foot, or occasionally on the dorsum of the foot
• exacerbated by vigorous sports activities
• Stiffness of the hindfoot
• Frequent ankle sprains
• Progressive deformity of foot: flat foot
 Signs
• Flat foot appearance , with external rotation of foot , and abduction
of forefoot
• Restricted ROM of hindfoot ( subtalar inversion and eversion)
• Joint motion is more preserved in calcaneonavicular
coalition
• Increased foot progression angle,
• Loss of hindfoot inversion occurs during a toe rise
 IMAGING
..
• X-ray : views usually performed are :
• 45 degree lateral to medial oblique view: to
visualise calcaneonavicular coalition

• Harris axial view : to visualise talocalcaneal

coalition across medial subtalar joint

• Lateral view of foot : to see for elongated

anterior projection of the calcaneus, the so-
called anteater’s nose, an anterior beak on the
talus
IMAGING
CT SCAN:
• Best imaging modality for the diagnosis of coalition
• Denotes extent and type of coalition
• Based on CT, KUMAR et al .classified coaitions into : type I- osseous, type II-
cartilaginous, type III- fibrous
• *non osseous are more symptomatic
MRI: useful in fibrous coalitions and when CT is nondiagnostic
 TREATMENT
Options include :
• Conservative treatment:
• use of a firm orthosis,
• 4- to 6-week period of immobilization in a short-leg walking cast
• Surgery :
• Indication : failure to relieve symptoms from a trial of conservative
treatment
• Resection of coalition and interposition of soft tissue in gap
• Limited hindfoot fusion
• Triple arthrodesis- useful in cases of degenerative changes
 RESECTION OF CALCANEONAVICULAR BAR

MIDDLE FACET TALOCALCANEAL COALITION RESECTION

 ACCESSORY NAVICULAR
• First described by Bauhin in 1605

• Aka accessory scaphoid, accessory navicular,

prehallux, and os tibiale externum

• a congenital anomaly in which the

tuberosity of the navicular develops from a
secondary center of ossification and located
on the medial aspect of the arch in
association with the navicular.
 ACCESSORY NAVICULAR AND FLAT FOOT
Kidner’s hypothesis : Flat foot in presence of an accessory navicular had one of
three causes:
• Alteration of the line of pull of the posterior tibial tendon
• Forcing of the posterior tibial tendon by the accessory navicular to
become more of an adductor than a supinator of the forefoot, thereby
decreasing support for the longitudinal arch;
• Impingement of the accessory navicular against the medial malleolus as the
foot adducts, which tends to keep the foot in an abducted position and thus
partially flattens the longitudinal arch.
 TYPES
• Three types described by COUGHLIN
• Type I : small, not attached to navicular, probably sesamoid in tibialis posterior

• Type II: definite part of the body of the navicular, separated by cartilaginous plate
Type III : united by a bony ridge, producing a cornuate navicular.
CLINICAL
FEATURES
• Asymptomatic –most of the time
• Can become symptomatic in childhood or early adulthood

• In children, the symptoms are usually caused by pressure of the accessory bone
against the shoe.

• Progressive flattening of the longitudinal arch.

• In adults, symptoms usually develop after trauma to the foot, often

resulting from a twisting injury.
IMAGIN
G
TREATMENT
NON SURGICAL OPTIONS:

◦In cases of asymptomatic incidental findings- reassurance

◦Shoe changes to reduce pressure over the area
◦In acutely symptomatic cases after an injury - immobilization in a below-
knee walking cast, followed by the use of a longitudinal arch support
◦Occasionally use of steroid may provide a relief
 SURGICAL OPTION : THE KIDNER
PROCEDURE
• Excision of the accessory navicular with or
without the plication of posterior tibial
tendon.

• Posterior tibial tendon is detached from the

insertion on navicular and rerouted in
plantar to dorsal direction and sutured on
itself or surrounding periosteum.

• Rerouting is necessary only when there is

pes planus.
 POSTERIOR TIBIAL TENDON
INSUFFICIENCY(PTTI)

• Most Common cause of adult flat

foot
• The main functions of posterior tibial
tendon are:
• plantar flexion of ankle ,
• inversion of foot
• stabilization of the medial
longitudinal arch
PATHOGENESIS
STAGE 1: TIB POST INSUFFICIENCY-CHRONIC OVERLOAD,
MICROTRAUMA, INFLAMMATION

STAGE 2 : PTT TEAR- WATERSHED AREA

FAILURE OF STATIC STABILIZERS

STAGE 3:ARCH COLLAPSE

ARTHRITIS
 CLASSIFICATI
ON
• Originally developed by Johnson and Strom in 1989
• Modified bty Myerson et al.
STAGES FEATURES
I TENOSYNOVITIS; NO DEFORMITY ,TOE RAISE TESTS POSSIBLE
II LOSS OF PTT FUNCTION;HIND FOOT VALGUS, BUT FLEXIBLE
III FIXED HINDFOOT DEFORMITY (VALGUS);DEGEN. CHANGES MAY BE
SEEN

IV VALGUS POSITIONING AND INCONGRUENCY OF ANKLE JOINT

INCLUDING STAGE III FEATURES
PTTI : RISK FACTORS
•Obesity
•Pre-Existing Flat foot
•Diabetes
•Increasing age
•Corticosteroid Use
•Seronegative Inflammatory disorders
 CLINICAL
FEATURES
STAGE I : Inflammation
• Pain-initially medially but later on localised to lateral side, Swelling
• Tenderness over Tib post
• Loss of medial longitudinal arch
• Can do single heel test
STAGE II : Tib post rupture
• Pain, swelling
• Heel Valgus Deformity-Flexible
• Can’t do Single heel raise test , but can do double
heel raise
STAGE III : Fixed Deformity
• Pain-both medial and lateral side
• Fixed flat foot
• Stiff Subtalar joint
 IMAGING
• X RAY:
• Provides inferences to MLA loss, forefoot abduction,
• Helps in ruling out the other causes of MLA loss
• But, may be normal even with complete rupture of tendon
• USG
• To look for PTT Rupture
• MRI
• To see for the peritendinous fluid collection, cystic degeneration and distorted
anatomy
TREATMENT
STAGES TREATMENT OPTIONS
STAGE I • Rest, NSAIDs, Physiotherapy
• Corticosteroid injection
• Orthosis
• Rarely tenosynovectomy

STAGE II • Orthotic devices, Physiotherapy

• Surgical reconstruction-FDL/FHL transfer to augment PTT
• Spring ligament repair/reconstruction,
• Lateral column lengthening
 Contd..
STAGES TREATMENT OPTIONS
STAGE III • Orthotic devices
• Arthrodeses-isolated talonavicular, talonavicular and subtalar
arthrodesis, triple arthrodesis

STAGE IV • Orthotic treatment

• Arthrodeses- ankle/tibiotalocalcaneal/triple
• Ankle arthroplasty - if hindfoot deformity can be corrected
 SUMMARY
• Pes planus - presentation of various pathologies - leading to alteration medial
longitudinal arch support.
• Most important step for management - find out whether it is flexible or rigid.
• Understanding the pathoanatomy of condition requires the knowledge of
biomechanics of feet and anatomical variations in foot.
• Patient may present with pain or deformity of foot .
• Treatment options vary from mere counselling to very difficult procedures like
extensive soft tissue release and bony alignment.
REFERENCES:
Thank You