This document discusses flat feet (pes planus), including its anatomy, causes, types, symptoms, physical exam findings, and treatment options. Key points include:
- Pes planus is characterized by a low or absent medial longitudinal arch. It can be flexible or rigid.
- Causes include ligament laxity, obesity, muscle weakness, bony abnormalities, and tarsal coalitions.
- Treatment focuses on orthotics, stretches, braces, and surgery if conservative options fail. Surgical procedures include tendon lengthening, osteotomies, and fusions.
3. Also known as pes planus
Medial border of the foot is abnormally in contact with
the floor during weight bearing
Low or absent medial longitudinal arch
When associated with deformities of the hind, mid
and fore foot – pes plano valgus
4. ANKLE – plantarflexion and dorsiflexion
SUBTALAR (TALOCALCANEAL) – inversion and
eversion
MIDTARSAL – adduction and abduction, flexion and
extension, supination and pronation
5. Forefoot - abduction and supination (relative to hind foot)
Talar head - displaced medially, anteriorly and downwards
Calcaneum everts, dorsiflexes - hindfoot is in valgus
Navicular- subluxates dorso-laterally, uncovering the talar
head
The medial column of the foot appears to be longer than
the lateral column
6.
7. Navicular, cuneiform, cuboid become wedge-
shaped, with apex directed dorso-laterally
Plantar, spring and deltoid ligaments are stretched
Anterior, posterior tibial tendons and plantar
muscles are stretched whereas the achilles tendon
and peronei become adaptively shortened
Calluses develop over the medial bony
prominences
8. Meary’s angle - between long axis of talus and long axis of first
metatarsal on a standing lateral Xray
0 degrees – normal
0 – 15 degrees – mild
15 – 30 degrees – moderate
> 30 degrees – severe
The location of the sag, talo-navicular, naviculo-cuneiform or
both can also be determined
9.
10.
11.
12. Calcaneal pitch - angle between the plantar surface of the
calcaneum and horizontal on a lateral x-ray
Normal 15 degrees , in flat foot is decreased
May be 0 or negative in case of tightened TA
The talocalcaneal angle on an AP view is a marker of hind foot
valgus
Talus much more vertical than normal
13. Exact incidence not known
One of the most common orthopedic deformities
Affects 15 - 20% of adults, mostly asymptomatic
Of this 2/3rd
have flexible flatfoot , 1/4th
have a contracted tendo-
achilles associated with a flexible flatfoot and the remainder
have rigid flatfoot the most common cause being tarsal coalition
14.
15. The medial longitudinal arch normally develops during the first
decade of life
Therefore flatfeet are usual in infants, common in children and
rare in adults
FOOTNOTE - Flatfoot in an infant is actually a ‘fat foot’ as the
excessive amount of fat obscures the arches
16. An arched foot is a distinctive feature of man
A) Two longitudinal arches
◦ Medial longitudinal arch
◦ Lateral longitudinal arch
B) Transverse arch
17. 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
18. Ends :
Anterior : 1-3 MT heads
Posterior : Medial tubercle of calcaneum
Summit: Superior articular surface of body of talus
Pillars :
Anterior: Talus, navicular, 3 cuneiforms, 1-3 MT
Posterior: Medial half of calcaneum
19.
20. Shape of bones: wedge shaped with apex pointing downwards.
The talus acts as a key-stone
Intersegmental ties: ligaments and muscles
Spring ligament
Dorsal ligaments - interosseus talocalcaneal
ligament
Tendinous extensions of tibialis posterior
21.
22. Tie beams or bow strings : connect two ends of an arch
Medial part of plantar aponeurosis
Medial part of the flexor digitorum brevis
Abductor hallucis, flexor hallucis longus, flexor
hallucis brevis
Medial part of flexor digitorum longus.
23. Slings : suspend the arch from above
Tibialis posterior, Flexor digitorum longus,
Tibialis anterior and peroneus longus
Flexor hallucis longus - bulkiest and strongest
muscles supporting med arch
28. Inflammatory arthrosis, Traumatic arthrosis
Charcot foot
Residua of clubfoot
Contractures of peronei or TA - Rheumatoid arthritis, Gout,
Degenerative arthritis, Infection, Acute sprain, Osteochondral
fracture, Foot tumors especially osteoid osteoma
29. Hereditary condition
Marked ligamentous laxity
Deformity disappears when feet are freed of weight bearing
Weight bearing axis - shifted medial to normal position
Prolonged weight bearing in the everted foot - Heel cord
contractures ( flexible flatfoot associated with tight heel cord)
30. No broad consensus
Unstable architecture of tarsal bones
Congenitally short tendo achilles
Weakened muscle power
Ligamentous laxity
31. Age of presentation: adolescence
Usually bilateral and asymptomatic
Family history of flatfeet and joint hyper mobility
Pain, discomfort, burning sensations and fatigue on
activity and prolonged standing, cramping at night
Felt around the navicular, talocalcaneal joint, below the
medial malleolus or at the ant. or post. extremities of the
plantar ligaments
32. Flatfoot only on weight bearing
Deformity correctable on passive manipulation by placing the foot in
equinus and inverting the heel
Deformity correctable on tip toe standing
Deformity correctable by voluntarily contracting the tibialis and long toe
flexors
Jack’s (great toe extension) test - the arch can be restored by simply
dorsiflexing the great toe – suggests that sag is at the
naviculocuneiform level
33. Examine the tendo-achilles for tightness (TA contracture tends makeS
flexible flatfoot symptomatic)
Short tendo-achilles: limited dorsiflexion(not able to walk on heels)
Harris and Beath documented that presence or absence of the
longitudinal arch did not corelate with the disability and a flatfoot was
compatible with normal function unless associated with a tight tendo-
achilles
Examine ROM of ankle,subtalar, midtarsal joints
Examine the gait
Generalized ligamentous laxity
Hypermobility of the subtalar and mid-tarsal joints: the forefoot can be
bent outwards and upwards to an unusual degree
34. Spine, hips and knees should be examined
General examination for neuromuscular abnormalities
Don’t forget to examine the shoes
shoes show excessive wear along the medial border
Pedobarography
A record of pressures can be obtained by making the patient to
stand and walk on a force plate. Mainly used to compare pre
and post operative function
37. Physiological flexible flatfoot with full ROM is
asymptomatic
It does not cause pain or disability
Xrays are not indicated and treatment is not required
Child should be left alone
If symptomatic always look for associated causes
most commonly tight heel cord
38. Mainstay of treatment as
This is what is required in majority
Condition is essentially benign
Only symptomatic treatment possible
No change in ultimate shape of the foot
FOOTNOTE – it is the parents and grand parents
who need treatment and not the child
39. Conservative treatment should always be
tried first
Arch supports, rubber inserts, Plastizote
Whitman valgus brace
UCBL (University of California
Biomechanics Laboratory) heel inserts
Shoe modifications –Thomas heel or a 14
inch wedge on the inner border
Custom molded orthotics
40.
41.
42. Do not alter underlying structural fault
Do not encourage redevelopment of the arch
Running sports shoes have been found to be as effective as
traditional orthoses and are more socially acceptable
FOOTNOTE - They reduce shoe wear and are said to be more
effective in treating shoes rather than feet
43. Toe-walking and multiple toe-ups
If tendo-achilles is contracted, stretching it actively and
passively is an important form of management
Grasping marbles with toes Heel to toe walking
Playing in sand
Ballet dancing
Walking on a supination board
FOOTNOTE - There is no scientific study evaluating the
effectiveness (or lack of it) of these exercises
44.
45. Reserved for patients with intractable symptoms
unresponsive to shoe or orthotic modifications and
who are unable to modify pain producing activity
Limitation of daily activities is an indication for
surgery
FOOTNOTE - Surgery for flexible flatfoot should not
be performed for cosmetic reasons
46. Soft tissue procedures – achilles tendon lengthening
Arthroeresis of the subtalar joint
Osteotomy - lateral collumn lengthening (DILLWYN EVANS,
PHILIPS, MOSCA, ANDERSON AND FOWLER), posterior calcaneal
osteotomy (GLEICH, KOUTSOGIANNIS), transverse calcaneal
osteotomy to raise the floor of the sinus-tarsi (CHAMBERS,
MILLER), osteotomies of medial cuneiform and cuboid
Arthrodesis – limited medial collumn arthrodesis (HOKE, DURHAM,
CALDWELL, COLEMAN), subtalar arthrodesis (these procedure
should be condemned as subtalar motion is lost and arthritic changes
invariably develop in the other tarsal joints), triple arthrodesis
(indicated as a salvage procedure when other procedures have
failed)
47. Arthrodesing procedures should be delayed until 10
and preferably 15 years
Before 10 years arthrodesis is difficult because of
excessive cartilaginous component of tarsal bones
Subsequent bony growth is retarded
Patient must be prepared to accept permanent loss of
inversion-eversion motion
48. Achilles tendon lengthening is included if the ankle lacks at
least 10 degrees of dorsiflexion with the knee extended
If patient has severe enough symptoms to warrant surgery,
then heel cord lengthening should be part of a
comprehensive procedure to reconstruct the arch
TECHNIQUE
3 small insicions( 2 medial, 1 lateral) along the length of the
tendon
Tendon is cut from midline outwards
Tendon sheath is repaired to prevent scarring
Closure is done with knee extended and ankle dorsiflexed
Long leg cast with ankle in neutral is given for 6 weeks
49.
50. A silicone or silastic implant (Smith –STA peg) is placed into
the sub talar joint
The plantar flexed posture of the talus and valgus at the
subtalar joint is limited by the interposition peg
Generally performed in young children
Potential complications (such as synovitis, peroneal spastic
flatfoot, stiffness of the sub talar joint and foreign body
reaction) are many
95% success has been claimed but this procedure requires
further investigation
51.
52. TECHNIQUE
Elevation of tibialis posterior tendon
Elevation of osteoperiosteal flap from proximal to distal
Naviculocuneiform arthrodesis
Advancement of osteoperiosteal flap
Advancement of tibialis posterior
53.
54. Displacement of the posterior half of the calcaneus
medially
Reestablishes the weight bearing line
Indicated in cases with excessive heel valgus
56. Osteotomy is fashioned in a coronal plane 1.5 cm
posterior to the calcaneocuboid joint between the
anterior and middle facets
This is not a simple opening wedge osteotomy, but
rather a lengthening distraction wedge osteotomy,
and it requires a trapezoid graft
Tricortical iliac crest graft is inserted between the
anterior and middle facets of the calcaneus
Additional internal fixation is required
57.
58.
59. Nonunion of calcaneal graft
Displacement of the graft requiring revision
Diplacement of the calcaneocuboid joint
Recurrence of deformity or pain
60. Indicated for correction of residual deformities in flat foot
Forefoot supination is corrected by a plantar medial closing
wedge osteotomy of first cuneiform
63. Cannot be passively manipulated without causing
pain
Feet are flat - regardless of weight bearing / position
Pain is usually a prominent symptom.
64. Thin or thick bar composed of bone (synostosis), cartilage
(synchondrosis) or fibrous tissue (syndesmosis) connects tarsal
bones
Failure of embryonic segmentation
Calcaneum is held in eversion
An irritative focus is produced which causes painful spasm of the
peronei
Impossible for the patient to walk on the lateral border of the
foot due to limited inversion
Mechanics of the tarsus is impaired and abnormal stresses result
casing sec. degenerative arthritis
65. Symptoms : do not develop until ossification of the fibrous
syndesmosis or the cartilagious synchondrosis
Syndesmosis and synchondrosis are usually more troublesome
than synostosis
Symptoms – vague foot pain, difficulty in walking on uneven
surfaces, foot fatigue, painful limp
Tenderness is present along the bar
The condition is known to run in families
Auto. dominant inheritance with variable penetrance
50% bilateral
Incidence - 0.4-6%
67. Symptomatic at 8 – 12 yrs
Varying loss of subtalar motion
Best seen on a 45 degree lat oblique projection
Beaking of dorsal articular margin of talus is uncommon
CT is usually not required
68.
69.
70. Middle facet talocalcaneal coalition is most common
Symptomatic at 12 – 16 yrs of age
Marked reduction or absence of subtalar motion
Best seen on a Harris view – posterosuperior oblique projection
Talar beaking is commonly seen – traction spur and not a sign of
degenerative arthritis
CT is usually needed for diagnosis
71.
72.
73.
74. Most patients respond to conservative treatment –
Rest
Shoe inserts (arch supports)
Orthotics (AFO, Plastizote, UCBL insert)
Shoe modifications (high top shoes, Thomas heel, Whitman plate)
4-6 weeks of immobilization in a short leg walking cast with the foot
plantigrade may provide lasting relief of symptoms
Splintage with an outside iron and inside T-strap
75. Resection of the bar and interposition of muscle, fat
or gelfoam – should be performed before secondary
degenerative changes have set in
Calcaneal osteotomy can be combined to to correct
hind foot valgus
Subtalar arthrodesis
Triple arthrodesis
76.
77.
78.
79.
80.
81. Extensive talocalcaneal coalition
Multiple coalition
Development of sec. degenerative arthritis
Ball and socket ankle joint
When the coalition involves more than 50% articular surface
of talocalcaneal joint or more than 50% of the posterior facet
82. First described by Bauhin in 1605
Also called prehallux, accessory scaphoid, os tibiale externum,
os naviculare secondarium and navicular secundum
Separate ossification center for the tuberosity of the navicular
Prevalance 5-10%
83.
84. Cause and effect relationship with flatfoot has not been shown
3 types
Round sesamoid bone within TP tendon - rarely symptomatic
8-12 mm ossicle connected to the navicular by a synchondrosis. This
is the type that is usually symptomatic as the synchondrosis is at risk of
disruption from traction injury / shear forces
Navicular beak / Cornuate navicular -fusion of acc. navicular with the
primary navicular.
85. Usually asymptomatic, noticed incidentally
Presentation - adolescence
Pain over an enlarged area at the medial aspect of
the navicular just at the insertion of the tibialis
posterior tendon
Pain aggravated by wearing tight-fitting shoes
86. Accessory navicular is best seen on the external oblique view
Accessory navicular ossifies even later than a normal navicular
which is the last tarsal bone to ossify
CT can identify an accessory navicular
Bone scan can identify a hot accessory navicular
87. Soft pads, avoid wearing tight fitting shoes
Special shoes, valgus correcting shoe inserts( UCBL
devise)
Steroid and analgesic injections
Strenghening of tibialis tendon and treatment of
tendonitis
Immobilization in a short leg cast
88. Simple excision of the accessory navicular shelling it out of the
post. tibial tendon
Navicular is resected until it is slightly depressed relative to the
talus and cuneiform
Bone wax is applied to the to prevent regrowth
Good or excellent result in 93% cases
89. Involves excision of the accessory navicular with re-routing of
the central slip of the tibialis posterior laterally onto the plantar
surface of the navicular, where it is sutured under tension to the
surrounding ligaments
Gives no added advantage in short term and long term follow up
and therefore the simpler procedure is preferred
91. Congenital rigid flat foot, rocker bottom foot, convex
pes valgus or teratologic dorsolateral dislocation of
the talo-naviculo-cuneiform joint
First description by Henken in 1914
Characteristic features described by Lamy and
Weissman
92.
93. Congenital dislocation of talonavicular joint such that the talus is
disposed vertically with its head forming the most prominent part of the
sole
The navicular is displaced dorsolaterally firmly lodged on to the neck
of the talus, preventing reduction. The navicular abuts the ant. surface
of the tibia
The calcaneum is displaced posterolaterally in relation to the talus, is
rigidly locked into equinus and in contact with the distal fibula
The angle between the long axis of the talus and calcaneum is
markedly increased
The forefoot is deviated outwards and dorsally and hence the sole
has a convex contour
94.
95. Dorsolateral dislocation or extreme subluxation of
calcaneocuboid joint might occur
Abnormal relationship of tarsal bones remain constant
whether the foot is plantar flexed or dorsiflexed, this is in
contrast to congenital flexible flatfoot
Achilles tendon is contracted, ant. tibial and peroneal tendons
are taught
The subtalar joint is abnormal with the anterior facet absent
and the middle facet hypoplastic
96.
97. Adaptive changes occur in the tarsal bones with weight bearing
The talus becomes shaped like an hour glass, with its
longitudinal axis almost same as the tibia
Only the posterior 1/3rd
of the superior articulating surface of the
tibia articulates with the tibia
Anterior part of the plantar surface of the calcaneus becomes
rounded
Callosities develop beneath the anterior end of the calcaneus
and along the medial border of the foot superficial to the head of
the talus
98. Muscle imbalance
Intra-uterine compression
Arthrogryposis
Autosomal dominant transmission
Arrest of fetal development of the foot between 7th
and 12th
weeks of gestation
99. Spina bifida
AMC
Trisomy of Ch-13, 14, 15, 18
Microcephaly
Prune belly syndrome
Spinal muscular atrophy
Neurofibromatosis
Congenital dislocation of hip
CNS abnormality can produce this deformity by muscle
imbalance( weak posterior tibial and strong peroneals)
100. Usually bilateral
Sole is characteristically convex at birth, so that it resembles
the bottom of a rocking chair and hence the name
Dorsolateral fold is deep and situated at the mid-tarsal area
Talar head is prominent over the medial and plantar aspects
Deformity from the outset is rigid
Deformity may be so severe that heel might not touch the
ground at all
Gait is awkward and resembles a waddle
Shoes are rapidly worn out over the inner sides
Pain - at adolescence or soon thereafter
102. Calcaneus is held in eversion by contracted interosseous
ligament, bifurcated ligament and calcaneofibular ligament
Calcaneus is fixed in equinus by contracted posterior
capsule and achilles tendon
Dorsal capsules of talonavicular, calcaneocuboid joints and
tibio-navicular portion of the deltoid ligament are markedly
contracted and prevent reduction
Tibialis anterior, long toe extensors, peroneus brevis and
triceps surae are contracted
Posterior tibial and peroneal tendons may be displaced
anteriorly so that they act as dorsiflexors rather than plantar
flexors
103.
104. Forefoot dorsiflexors are contracted
Calcaneonavicular ligament is elongated and attenuated
Posterior tibial tendon becomes attenuated as it passes over the
displaced head of talus
If deformity persists into late childhood, alterations in the bony
shape develop that encourage redisplacement even after
surgery
Talus assumes hour-glass constriction, calcaneus becomes
curved dorsally at its anterior end becoming beak shaped and
navicular becomes wedge shaped
105. Difficult to treat tends to recur
Manipulation and cast application are rarely successful
and if reducible by closed means a diagnosis of oblique
talus is made
But manipulation and serial casting keeps the skin and
soft tissues stretched
Open reduction is generally required
106. 1 - 4 years : soft tissue release and open reduction
(KUMAR, COWELL, RAMSEY)
4 - 8 years : soft tissue release and open reduction with
Grice-Green subtalar extra-articular arthrodesis
>12 years, failure of above procedures : triple
arthrodesis
Children > 3 yrs with severe deformity generally require
navicular excision at the time of open reduction
107. Should be done before 2 yrs
Best done as a single stage release at 1 yr
STEPS
Dorso-lateral soft tissue release
Medial soft tissue release
Reduction of talonavicular and calcaneocuboid jts
Posterior soft tissue release
Internal fixation
108.
109.
110.
111.
112. Results are satisfactory if surgery is done before 27
months
All feet have some residual midfoot sag and forefoot
abduction and some have decreased motion
Commonest reason for surgical failure is inadequate
reduction of the navicular
113. Aseptic necrosis of the navicular
Aseptic necrosis of the talus
These can be averted by limited amount of dissection
114.
115. Most common cause of adult onset acquired flat foot
TREATMENT
NSAIDS
Intrasynovial injection of corticosteroids
Splintage with outside iron and inside T strap
116.
117. Unilateral deformity that develops rapidly
History of trauma
Young patient- tendon transfer using flexor digitorum longus
Elderly- splintage
If this fails and symptoms are marked triple arthrodesis