This document provides information about pes planus (flat foot), including its components, classification, examination, and treatment. Pes planus is characterized by a lowered or absent medial longitudinal arch. It can be flexible or rigid depending on joint mobility. Flexible flat foot is more common and usually asymptomatic, especially in children. Treatment focuses on orthotics, exercises, or surgery if conservative measures fail. Surgical options include tendon lengthening, arthrodesis, and osteotomies to realign the foot structure.

1. PES PLANUS

2. PES PLANUS (FLAT FOOT)
• 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 forefoot –
called as pes plano valgus

4. JOINTS MOVEMENTS
Ankle Plantarflexion and dorsiflexion
SUBTALAR (TALOCALCANEAL) inversion and eversion
MIDTARSAL adduction and abduction, flexion and
extension, supination and pronation

5. COMPONENTS OF FLAT FOOT
 The medial column of the foot appears to be longer
than the lateral column
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

6. NORMAL FOOT PES PLANUS

7. SECONDARY CHANGES
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. RADIOLOGICAL EXAMINATION
1.Standing anterior-posterior (AP) (dorsoplantar),
2.lateral, and oblique views
3.Harris-Beath views if a tarsal coalition is suspected

9. RADIOLOGICAL FEATURES
• There are basically 3 components that are involved in producing the alignment
abnormalities of symptomatic adult flatfoot:
1.Forefoot abduction
2.Collapse of the longitudinal arch
3.Hindfoot valgus

11. 1. Forefoot abduction

12. a) Talonavicular
coverage angle
Two lines are drawn, one
connecting the edges of the
articular surface of the talus,
and one connecting the edges
of the articular surface of the
navicular. The angle formed by
these two lines is
the talonavicular coverage
angle
Normally it is less than 7
degrees

13. • Lateral subluxation of
the navicular on the
talus (or talonavicular
uncoverage)
• This is an indication of
forefoot abduction

14. b) AP Talar - 1st
metatarsal angle
Normal talar-1st
metatarsal angle on AP
view.
A line drawn trough the
mid-axis of the talus
passes through the base
of the first metatarsal
and is angled laterally in
relation to the long axis
of the shaft of the
metatarsal.

15. Abnormal talar-1st
metatarsal angle,
angled medial to the
first metatarsal.
It indicates
pes planus.(forefoot
abduction)

16. 2.Collapse of the
longitudinal arch

17. a) Meary’s angle
between long axis of talus and long axis of first metatarsal on a standing lateral X
ray
 long axis of the talus should nearly bisect the navicular and first metatarsal
shaft
0 degrees – normal
0 – 15 degrees – mild
15 – 40 degrees – moderate
> 40 degrees – severe
 The location of the sag, talo-navicular, naviculo-cuneiform or both can
also be determined

18. Normal Meary's angle. The long axis of the talus
intersects that of the first metatarsal

19. The long axis of the talus is angled plantarward in relation
to the first metatarsal, consistent with pes planus

20. b) Calcaneal pitch –
A line is drawn from the plantar-most surface of
the calcaneus to the inferior border of the distal
articular surface. The angle made between this line
and the transverse plane is the calcaneal pitch
Normal 17-32 degrees,
in flat foot is decreased
May be 0 or negative in case of tightened TA

21. Normal calcaneal pitch.

22. Decreased calcaneal pitch
indicating pes planus

23. 3. Hindfoot valgus

24. a) Lateral Talocalcaneal Angle
(Turco’s angle)
The normal range is 25-45 degrees

25. Increased talocalcaneal angle indicaitng
hindfoot valgus in pes planus.

26. b) AP Talocalcaneal angle
(Kite's angle)
This is the angle
formed by the
intersection of a line
bisecting the head and
neck of the talus and a
line running parallel
with the lateral surface
of the calcaneus. The
range of normal for
adults is 15 - 30°

27. Abnormally
increased AP
talocalcaneal
angle, more
than 30
degrees
indicating
hindfoot valgus
in pes planus.

28. 4.CYMA line

29. CYMA line
is an architectural term
designating the union of
two curve lines. A normal
midtarsal joint should
create a smooth cyma
between the talonavicular
joint and calcaneocuboid
joint on both the AP and
lateral views

30. Normal CYMA line connecting talonavicular joint and
calcaneocuboid joint is smooth and continuous.

31. • If the cyma line is broken it suggests
“shortening” of the calcaneus
relative to the talus
• This is often just a radiographic
shortening possibly due to rotation
of the talus on calcaneus (typically
seen in a patient with adult flatfoot
including loss of the medial arch)

32. Broken Cyma line of pes planus.

33. HOW COMMON IS FLAT FOOT?
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

34. HOW COMMON IS FLAT FOOT?
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
Flatfoot in an infant is actually a ‘fat foot’ as the excessive amount of fat
obscures the arches

35. ANATOMY OF THE ARCHES OF A
NORMAL FOOT
An arched foot is a distinctive feature of man
A) Two longitudinal arches
• Medial longitudinal arch
• Lateral longitudinal arch
B) Transverse arch

36. 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

37. FORMATION OF MEDIAL ARCH
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

38. FACTORS RESPONSIBLE FOR MAINTENANCE OF MEDIAL ARCH (as
compared to stone bridge)
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
Tie beams or bow strings : connect two ends of an arch
• Medial part of plantar aponeurosis
• Medial part of the FDB
• Abductor hallucis, FHL, FHB
• Medial part of FDL
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

40. Flat foot classification based on mobility of tarsal joints
FLEXIBLE
• Physiologic – due to
ligamentous laxity in 1st
decade
• Hypermobile flatfoot –
excessive ligamentous
laxity – familial, down’s,
marfan’s, ehlers-danlos,
osteogenesis imperfecta
• Bony abnormalities –
hypoplasia of
sustentaculum tali,
hypoplastic calcaneum
• Occupational
• Obesity
RIGID
• Congenital
• Tarsal coalition
• Vertical talus
• Acquired
• 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

41. Flexible flatfoot

42. FLEXIBLE FLAT FOOT
• MOTOR WEAKNESS – PTTD, accessory navicular, muscular dystrophy,
peripheral nerve lesions, cerebral palsy, spinal cord conditions like polio,
myelodysplasia, Werdnig – Hoffman disease, spina- bifida
• SECONDARY TO ANATOMIC DEFECTS ELSEWHERE :
• Ext. rotation of the limb
• Genu valgum
• Equinus deformity of the ankle (tight tendo- achilles)
• Varus deformity of the foot

43. FLEXIBLE FLAT FOOT
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)

44. ETIOLOGY
No broad consensus
Unstable architecture of tarsal bones
Congenitally short tendo achilles
Weakened muscle power
Ligamentous laxity

45. HISTORY
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

46. PHYSICAL EXAMINATION
Flatfoot only on weight bearing
Deformity correctable on tip toe standing
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

47. Arch appearing on tip toe standing

48. PHYSICAL EXAMINATION
Examine the tendo-achilles for tightness (TA contracture tends to
make 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

49. PHYSICAL EXAMINATION
 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

50. Footprints made with the aid of an ink pad show the difference between normal sole contact and
flat-footed contact.
(a) Normal footprint, showing the main contact areas across the anterior metatarsal arch, the
lateral border of the foot and the heel, with a ‘hollow’ corresponding to the medial arch.
(b) Flat-footed contact, across the sole to the medial side of the foot

51. TREATMENT
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

52. PARENT EDUCATION AND
REASSURANCE
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
– it is the parents and grand parents who need treatment and not
the child

54. ORTHOTICS
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

55. • Medial heel wedge

56. LIMITATIONS
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
They reduce shoe wear and are said to be more effective in treating
shoes rather than feet

57. EXERCISES
Excercises are designed to improve the
strength of invertors and the plantar flexors
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
There is no scientific study evaluating the effectiveness (or lack of
it) of these exercises

58. SURGICAL TREATMENT
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
Surgery for flexible flatfoot should not be performed for
cosmetic reasons

59. SURGICAL OPTIONS
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

60. TA LENGTHENING
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

62. DURHAM FLATFOOT PLASTY
TECHNIQUE
Elevation of tibialis posterior tendon
Elevation of osteoperiosteal flap from proximal to distal
Naviculocuneiform arthrodesis
Advancement of osteoperiosteal flap
Advancement of tibialis posterior

65. POSTERIOR CALCANEAL
DISPLACEMENT OSTEOTOMY
Displacement of the posterior half of the calcaneus medially
Reestablishes the weight bearing line
Indicated in cases with excessive heel valgus

66. Koutsogiannis calcaneal osteotomy

67. ANTERIOR CALCANEAL LENGHTENING
DISTRACTION OSTEOTOMY
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

69. COMPLICATIONS
Nonunion of calcaneal graft
Displacement of the graft requiring revision
Diplacement of the calcaneocuboid joint
Recurrence of deformity or pain

70. Plantar Flexion Opening Wedge Medial
Cuneiform Osteotomy
Hirose and Johnson
Indicated for correction of residual deformities in flat foot
Forefoot supination is corrected by a plantar medial closing
wedge osteotomy of first cuneiform
The goal is to plantar flex the first ray down to the level of the fifth
metatarsal to restore Cotton's normal “tripod” configuration.

72. Rigid flat foot

73. RIGID (OR FIXED) FLAT FOOT
Tarsal coalition (peroneal spastic flatfoot, congenital rigid
flatfoot) [most common cause]
Heel cord tightening
Accessory navicular
Vertical talus

74. RIGID FLATFOOT
Cannot be passively manipulated without causing pain
Feet are flat - regardless of weight bearing / position
Pain is usually a prominent symptom.

75. TARSAL COALITION
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

76. TARSAL COALITION
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 active adolescents with dorsolateral foot pain
around the sinus tarsi, 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%

77. CALCANEONAVICULAR COALITION
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

79. TALOCALCANEAL COALITION
Middle facet talocalcaneal coalition is most common
Symptomatic at 12 – 16 yrs of age
Marked reduction or absence of subtalar motion (cardinal sign)
Best seen on a Harris Beath axial calcaneal view – posterosuperior oblique
projection
Talar beaking is commonly seen – traction spur and not a sign of degenerative
arthritis
CT is usually needed for diagnosis(in coronal plane at 3mm increments)

81. Harris axial
calcaneal
view for
middle facet
coalition

82. CT scan showing middle facet coalition

83. TREATMENT
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

84. SURGICAL OPTIONS
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

85. Resection of calcaneonavicular tarsal coalition.
A, Before surgery. B, Direction of osteotome.
C, After resection.

86. Resection of middle facet tarsal coalition. A, Sheath is opened and retracted dorsally or
plantarly. B, Coalition is removed with osteotome until it is flush with posterior facet.

87. INDICATIONS FOR TRIPLE
ARTHRODESIS
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

88. SUBTALAR ARTHROEREISIS
• The concept
•“limiting the ability of the
calcaneus to externally rotate
and the talus to internally
rotate”
• maintenance of correction of the arch was possible.

89. Maxwell and Cerniglia biomechanical classification of sinus tarsi implants.
Self-locking wedge
inserted in a screw
fashion
between the lateral
process of the talus and
the anterior
process of the
calcaneus and prevents
external rotation of the
calcaneus on the talus

90. Axis-altering device.
intraarticular device
that is inserted under
the
lateral process
of the talus in the
lateral most portion of
the subtalar joint and
elevates the lateral
aspect of the talus

91. Impact-blocking device
is inserted in bone in the
floor of the sinus tarsi and
acts in a similar fashion to
the selflocking
wedge by preventing
external rotation of the
calcaneus
under the talus

92. •In summary, after review of the literature,
several findings seem to be consistent:
• 1. Insertion of a sinus tarsi blocking implant, whichever design is used, seems
consistently to reduce the pes planus deformity and, at least in short-term
follow-up studies
• 2. A significant incidence of sinus tarsi pain requiring implant removal has
been noted, and this pain does not always resolve with removal of the
implant.

93. • 3. Follow-up can be characterized as midterm at best with no truly long-term
studies available at this point.
• 4. Further studies are needed before these devices can be recommended for
general use.
• 5. The literature appears to indicate that the best use of these implants is in
children with symptomatic pes planus who have combined neuromuscular
disorders

94. ACCESSORY NAVICULAR
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%

96. ACCESSORY NAVICULAR
• Cause and effect relationship with flatfoot has not been shown
• 3 types
1. Round sesamoid bone within TP tendon - rarely symptomatic
2. 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
3. Navicular beak / Cornuate navicular -fusion of acc. navicular with
the primary navicular.

97. SYMPTOMS
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

98. INVESTIGATIONS
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

99. TREATMENT
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

100. SURGERY
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

101. KIDNER’S PROCEDURE
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

104. CONGENITAL VERTICAL TALUS
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

105. Bilateral congenital vertical talus in 14-month-old
child

106. X-ray shows the vertical talus pointing downwards towards the sole and the
other tarsal bones rotated around the head of the talus

107. after bilateral operative correction at age 14 months in which
transverse circumferential approach was used.

108. CONGENITAL VERTICAL TALUS
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

109. CONGENITAL VERTICAL TALUS
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

110. Plantar flexion lateral stress radiographs
in diagnosis of congenital vertical talus.
In normal foot, long axis of first metatarsal passes
plantarward to long axis of talus.

111. In congenital vertical talus, long axis of first metatarsal remains
dorsal to long axis of talus, indicating dorsal dislocation of
midfoot and forefoot.
with equinus deformity of calcaneus.

112. CONGENITAL VERTICAL TALUS
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

113. ETIOLOGY
Muscle imbalance
Intra-uterine compression
Arthrogryposis
Autosomal dominant transmission
Arrest of fetal development of the foot between 7th
and 12th
weeks of gestation

114. CLINICAL PICTURE
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

115. DIFFERENTIAL DIAGNOSIS
Idiopathic flatfoot
Paralytic flatfoot
Spurious correction of clubfoot
Talipes calcaneovalgus (benign condition easily amenable to
correction)
Tarsal coalition

116. PATHOLOGY
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

117. PATHOLOGY
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

118. NONOPERATIVE TREATMENT
• Difficult to treat tends to recur
• Serial casting to stretch the foot in plantarflexion and
inversion while counterpressure is applied to the medial
aspect of the talus
• Reverse Ponseti method
• Complete correction rarely achieved.
• Open reduction is generally required

119. SURGICAL OPTIONS
 1 - 4 yrs : soft tissue release, open reduction and realignment of the
talonavicular and subtalar joints (KUMAR, COWELL, RAMSEY)
 Children > 3 yrswith severe deformity generally require navicular
excision at the time of open reduction
4 - 8 yrs : soft tissue release and open reduction with Grice-Green
subtalar extra-articular arthrodesis
>12 yrs failure of above procedure striple arthrodesis

120. OPEN REDUCTION AND REALIGNMENT OF
TALONAVICULAR AND SUBTALAR JOINTS
(KUMAR, COWELL, RAMSEY)
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

121. •Kodros and Dias reported a single-
stage procedure
• in which a threaded Kirschner wire is used as a “joystick”
• To manipulate the talus into correct position.
• The corrected position is held with threaded Kirschner wires across
the talonavicular and subtalar joints

122. Single-stage correction of congenital vertical talus.
Threaded Kirschner wire is placed axially in vertical talus
from posterior and is used as “joystick” to manipulate talus into
reduced position.

123. Wire is advanced across talonavicular joint.

124. RESULTS
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

125. COMPLICATIONS
Aseptic necrosis of the navicular
Aseptic necrosis of the talus
These can be averted by limited amount of dissection

126. ADULT ONSET
ACQUIRED FLATFOOT

128. Examination of the flatfoot compares the (A) nonweightbearing and (B) weightbearing arch of the foot. As the arch
depresses,
(C) the forefoot abducts and (D) the lesser toes become visible upon posterior observation of the foot. The relaxed
calcaneal stance position is viewed standing behind the patient.
A flatfoot deformity will demonstrate heel eversion that is accentuated with apparent bowing of the
tendo-Achilles (Helbing sign).
The too many toes sign, indicative of excessive forefoot abduction in the flatfoot, may also be noted.

129. POSTERIOR TIBIAL TENDON
DYSFUNCTION
Most common cause of adult onset acquired
flat foot
The components of the deformity are
1. hindfoot valgus,
2. midfoot abduction at the midtarsal joint,
3. forefoot pronation, primarily at the midtarsal
joint.

130. • Chronic tenosynovitis (either traumatic, degenerative, or secondary to
inflammatory arthritis), loss of continuity of the tendon (either complete
or incomplete), and loss of the normal anatomical relationships of the
tendon to its insertion or insertions (the accessory navicular or prehallux
syndrome)
• may render the posterior tibial tendon insufficient to perform its tasks of
plantar flexion and inversion
• and stabilization of the medial longitudinal arch.

131. •The classification system
originally developed by
Johnson and Strom in 1989

133. Teatment of stage 1

134. Teatment of stage 2
Conservative
management
of stage II disease often is successful, and
most patients obtain pain relief with
application of an orthotic device that has
a medial post and
a double upright
AFO with a medial T-strap.
The brace is configured to allow
20 to 30 degrees of plantar
flexion and 10 degrees of ankle
extension.

136. Teatment of stage 3
arthrodesis is
indicated if
conservative
measures, including
a double upright
ankle-foot orthosis,
have failed.

137. Treatment of stage 4
• For rigid deformities, the procedure of choice usually is arthrodesis of
the ankle or tibiotalocalcaneal arthrodesis
• In a select group of patients with flexible, reducible deformity, less
than 10 degrees of tibiotalar tilt, and minimal lateral ankle joint
arthrosis
• Jeng et al. described a “minimally invasive”allograft technique for
deltoid ligament reconstruction for stage IV flatfoot deformity done in
conjunction with triple arthrodesis.

139. POSTERIOR TIBIAL TENDON
RUPTURE
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