Pes planus

PES PLANUS
PRESENTER
DR. RAMKRISHNA DAHAL
MS RESIDENT TUTH

OVERVIEW….
Anatomy of arches of foot
Definition and causations of pes planus
Special discussions on more common causes:
◦ Flexible flat foot
◦ Congenital vertical talus
◦ Tarsal coalition
◦ Accessory navicular
◦ Posterior tibial tendon disorder
Summary ..

ANATOMY OF 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
The medial longitudinal arch needs special mention in discussing the
aetiopathogenesis of pes planus
Clinically Oriented Anatomy Moore, Keith L.; Dalley, Arthur F.

BONES OF MLA..
Calcaneum, talus, navicular, three cuneiforms and first three metatarsals

SUPPORTS OF MLA..
Describing the arch supports includes basically 4 headings:

For MLA support:
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
The suspension arch is made by TIBIALIS ANTERIOR, TIBIALIS POSTERIOR AND
MEDIAL LIGAMENTS OF ANKLE JOINT

WHAT IS PES PLANUS??
A manifestation of various conditions in which the medial arch of the foot is diminished or
absent, allowing the entire sole to touch the ground.
May present as an asymptomatic incidental finding on examination or as a symptomatic
condition
Symptoms range from mild pain or restricted range of motion to severe disabling pain

ON PHYSICAL EXAMINATION..
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”
REST FINDINGS ARE DISCUSSED IN SPECIFIC TOPICS…

INCIDENCE..
A depressed longitudinal arch occurs in approximately 23% of the adult
population.
Of this population, approximately two thirds have a flexible, hypermobile
flatfoot with normal or increased mobility of the subtalar complex and ankle
joint.
Approximately one fourth of flatfeet exhibit a contracture of the triceps surae
associated with an otherwise typical hypermobile flatfoot, and this form of
flatfoot is a known cause of disability in army recruits.
The remainder of flatfeet are characterized by more rigidity of the subtalar joint,
typically seen with tarsal coalitions.
Tachdjian’sPediatricOrthopaedics,5th edition

CONGENITAL FLAT FOOT ACQUIRED FLAT FOOT
PES PLANOVALGUS ADULT FLEXIBLE FLATFOOT
CONGENITAL VERTICAL TALUS TARSAL COALITION
TENDON DYSFUNCTION-PTT,OR
PERONEAL TENDONS
POSTTRAUMATIC
IATROGENIC
ARTHRITIC
CHARCOT FOOT OR NEUROMUSCULAR
FLATFOOT

“…usual in infants, common in children, and within the normal range in adults..”
Staheli and colleagues
Exact incidence of flatfoot in children is unknown
PES PLANOVALGUS

Arch is usually obscured in an infant’s foot because of subcutaneous fat.
Longitudinal arch develops during the first decade of life.
The lateral talus–first metatarsal angle demonstrates a decrease in the amount
of plantar sag of the midfoot until 8 years old.

Painless most of the times.
On examination:
◦ Inspection:
◦ excessive eversion during weight bearing,
◦ the forefoot is usually abducted, producing a midfoot sag with lowering of the
longitudinal arch
◦ forefoot is actually supinated in relation to the hindfoot
◦ medial column of the foot appears longer than the lateral column
◦ 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

IS RADIOGRAPHY NECESSARY??
NOT NECESSARILY…
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
most compelling reason to rule out causes of the deformity
other than idiopathy

TREATMENT OF PES PLANOVALGUS..
Conservative Treatment
In a typical case of a hypermobile (postural) flatfoot,
no treatment is indicated in an asymptomatic pediatric patient.
Education and reassurance are the mainstays.
If an Achilles tendon contracture is present-
stretching exercises
TP strengthening exercises

Is there any role of orthoses??
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.
Wenger DR, Mauldin D, Speck G, et al: Corrective shoes and inserts as treatment for flexible flatfoot in infants and children, J Bone Joint Surg Am 71:800, 1989.

Surgical treatment:
Indications:
1. Intractable symptoms unresponsive to shoe or orthotic modifications
2. In individuals who are unable to modify the activities that produce pain
Surgical options include:
ARTHROEREISIS- limits the amount of valgus motion in the subtalar joint by using an
interposition peg
HEEL CORD LENGTHENING
SUBTALAR FUSION - only as salvage procedure.
LATERAL COLUMN LENGTHENING
IMBRICATION OF TALONAVICULOCUNEIFORM COMPLEX
CALCANEAL OSTEOTOMY
TRIPPLE ARTHRODESIS

Lateral column lengthening
Talonaviculocuneiform imbrication

CONGENITAL VERTICAL TALUS
A condition characterized by a fixed dorsal dislocation of the talonavicular joint
in conjunction with rigid hindfoot equinus
Aka congenital convex pes valgus, teratologic dorsolateral dislocation of the
talocalcaneonavicular joint
A cause of rigid pes planus
1 in 10000 live births
Mann’s Surgery Of The Foot And Ankle Ninth Edition

ETIOLOGY AND ASSOCIATIONS..
Etiology is not yet known
Autosomal dominant pattern of inheritance has been linked(12-20 % of idiopathic cases)
Gene mutations (HOXD10 )
Associations: associated congenital anomalies are found in approximately 60% of patients
in 10% of patients with myelomeningocele
in 11% of patients with arthrogryposis
trisomy 13,15 and 18
spinal muscular atrophy, neurofibromatosis, congenital dislocation of the hip
Kumar SJ, Guille JT, Lee MS, et al: Osseous and non-osseous coalition of the middle facet of the talocalcaneal joint, J BoneJoint Surg Am 74:529, 1992.

PATHOANATOMY
BONY CHANGES :
TALUS:
◦ hourglass shape ,equinus position
◦ longitudinal axis is almost the same as that of the tibia, and
◦ only the posterior one third of its superior articular surface articulates with the tibia.
NAVICULAR:
◦ articulates with the dorsal aspect of the neck of the talus and is locked there
◦ proximal articular surface is tilted plantarward
CALCANEUM:
◦ displaced posterolaterally in relation to the talus
◦ in contact with the distal end of the fibula
◦ tilted into equinus

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
PATHOANATOMY
Posterior tibial and peroneal tendons may be displaced anteriorly so that they act as dorsiflexors rather than plantar
flexors.

CLINICALLY..
ON INSPECTION:
a rocker bottom foot, the apex of which is at the talar head
deep creases dorsolaterally and below LM, callosities may be seen
hindfoot foot is everted into a valgus, externally rotated position
forefoot is abducted and dorsiflexed
ON PALPATION:
calcaneus is fixed in equinus, with 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…
X RAY:
LATERAL PROJECTION:
FORCED DORSIFLEXION LATERAL VIEW :
FORCED PLANTAR FLEXION LATERAL VIEW:

NORMAL FOOT
CVT FOOT

TREATMENT PRINCIPLES..
GOAL: To restore the normal anatomic relationships between the talus, the navicular, and the
calcaneus to provide a normal weight distribution through the foot
EARLIER BELIEF :
Major reconstructive surgery was necessary to correct the deformities in the majority of
patients though frought with substantial complications.
RECENT BELIEF :
Serial casting to stretch the contracted dorsal and lateral soft tissues and gradually reduce the
talonavicular joint followed by later minimally invasive procedures for final correction.

PRINCIPLES OF 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
Tachdjian has performed blind pinning of the talonavicular joint to maintain reduction
while gradually correcting the equinus contracture.
Tachdjian M: Pediatric orthopaedics, Philadelphia, 1990, Saunders.

CONCEPT OF REVERSE PONSETI CASTING??

During casting the foot is placed in extreme equino varus position .
Forefoot is adducted and inverted while applying upward pressure on the talar
head.
Congenital Vertical Talus In Freeman- Sheldon Syndrome.Treated with New Method (Reverse Ponseti method). Mukesh K, Chandrababu K K, Bhaskaran V K

PRINCIPLES OF SURGERY:
STAGES OF RELEASE AS ADVISED BY TACHDJIAN:
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
SOMETIMES EXCISION OF NAVICULAR MAY ALSO BE REQUIRED FOR THE REDUCTION

TARSAL COALITION:
Is an abnormal connection between two or more bones of the foot that may produce
pain and limitation of foot motion.
Fifty percent to 60% of tarsal coalitions are bilateral.
Incidence varies from 0.03% to 1.0%.
Tarsal coalition, rigid pes planus, and peroneal muscle spasm frequently are discussed
together as essential components of peroneal spastic pes planus.

TYPES OF TARSAL COALITIONS
Calcaneonavicular: more common form but less symptomatic
Talocalcaneal: more symptomatic form
Other rare forms :calcaneocuboid, naviculocuboid, naviculocuneiform, or
massive tarsal coalition
Although the exact cause is not known but genetic mutations with autosomal
dominant pattern of inheritance has been noted

ASSOCIATIONS
Cavovarus deformity and talipes equinovarus
Fibular hemimelia: “ball-and-socket” ankle
Nievergelt-pearlman Syndrome: massive tarsal and carpal coalitions
Apert Syndrome

SYNDROMIC COALITIONS

CLINICAL FEATURES..
Symptoms : Usually become symptomatic at /after 12-16 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, particularly running on uneven
surfaces
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
Ill sustained clonus on passive inversion
Increased foot progression angle, loss of hindfoot inversion occurs during a toe
rise

IMAGING..
X ray : views of feet that are performed are :
45 degree lateral to medial oblique view: to visualise calcanenavicular coalition
Harris 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

OTHER IMAGING MODALITIES..
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
Role of MRI: useful in fibrous coalitions and when CT is nondiagnostic
Role of tecnetium bone scan: increased uptake in areas of subtalar joint

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
The surgical options include :
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:
1605, Bauhin first described the accessory navicular.
Aka accessory scaphoid, accessory navicular, prehallux, and os tibiale externum
An accessory navicular is 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.

WHY IS ACCESSORY NAVICULAR IMPORTANT IN
DISCUSSING PES PLANUS??
Kidner’s hypothesis states that flatfoot deformity in presence of an accessory
navicular had one of three causes:
Alteration of the line of pull of the posterior tibial tendon as a result of
prominence created by accessory navicular
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 are described:COUGHLIN
Type I : small, well defined, not attached to navicular, probably sesamoid in
tibialis posterior

Type II: definite part of the body of the navicular, but the tuberosity is separated
by a fibrocartilaginous plate of irregular outline >> so basically a synchondrosis
Sella and Lawson have divided the type II into two more types as:
Type IIA Type IIB
under a tension force a shearing force
more at risk for an avulsion
injury
so more at risk of shear
fractures
Sella E, Lawson J: Biomechanics of the accessory navicular synchondrosis,Foot Ankle 8:156–163, 1987.

Type III : united by a bony ridge, producing a cornuate navicular.

CLINICAL FEATURES..
Can become symptomatic in childhood or early adulthood
In children, the symptoms are usually caused by pressure of the accessory bone
against the shoe. At times, the condition is associated with progressive flattening
of the longitudinal arch.
In adults, symptoms usually develop after trauma to the foot, often resulting
from a twisting injury.

IMAGING..

TREATMENT OPTIONS..
NON SURGICAL OPTIONS:
◦ In cases of asymptomatic accidental 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
A procedure involving the 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.
Sometimes medial slide osteotomy of proximal fragment of calcaneum is also
added.

DISORDER OF POSTERIOR TIBIAL
TENDON AND PES PLANUS..
The main functions of posterior tibial tendon are:
plantar flexion of ankle , inversion of foot and stabilization of the medial
longitudinal arch
Insufficiency of PTT can be caused by :
• chronic tenosynovitis
• loss of continuity of the tendon
• loss of the normal anatomical relationships of the tendon to its insertion
Campbell’s Operative Orthopedics,12th Ed.

THE CHANGES THAT FOLLOW INCLUDE:
Spring ligament - significant stretching and elongation
Anterior or tibionavicular portion of the superficial deltoid ligament- elongate(MEDIAL
ANKLE INSTABILITY)
Ligaments over naviculocuneiform and cuneiform first metatarsal- elongate

CLASSIFICATION
Originally developed by Johnson and Strom in 1989
STAGES FEATURES
I TENOSYNOVITIS; TOE RAISE TESTS POSSIBLE
II LOSS OF PTT FUNCTION;HIND FOOT REMAINS FLEXIBLE
III FIXED HINDFOOT DEFORMITY (VALGUS);DEGEN. CHANGES MAY BE
SEEN
IV VALGUS POSITIONING AND INCONGRUENCY OF ANKLE JOINT
INCLUDING STAGE III FEATURES

CLINICAL FEATURES…
SYMPTOMS:
Primary complaint is pain-initially medially but later on localised to lateral side
Foot and ankle fatigue after only limited activity
Gradual or acute onset deformity of foot
SIGNS:
Flat foot deformity
Absence of heel varus on toe raise test
Altered gait pattern- absence of end stance hind foot varus position
Posterior tibial edema sign( Deorio et al.)

IMAGING..
X RAY:
Provides inferences to MLA loss, forefoot abduction, TA cont.
Helps in ruling out the other causes of MLA loss
But, may be normal even with complete rupture of tendon
WHAT TO SEE IN X RAYS??
TALUS FIRST METATARSAL ANGLE
LOSS OF HEIGHT OF MEDIAL CUNEIFORM
OVERLAPPING METATARSALS

MIMICKERS

ROLE OF MRI..
TO SEE FOR THE PERITENDINOUS FLUID COLLECTION, CYSTIC DEGENERATION AND DISTORTED ANATOMY

TREATMENT PRINCIPLES..
STAGES TREATMENT OPTIONS
STAGE I • Rest, nonsteroidal anti-inflammatory agents, and a short-leg walking cast
• Corticosteroid injection
• Physiotherapy
• Brace-medial heel wedge and medial forefoot post (TO KEEP HINDFOOT NEUTRAL)
• Rarely tenosynovectomy
STAGE II • Orthotic devices
• Physiotherapy
• Surgical reconstruction-FDL/FHL transfer w/o PTT augmentation, spring ligament
repair/reconstruction, lateral column lengthening

Contd..
STAGES TREATMENT OPTIONS
STAGE III • Orthotic devices
• Arthrodeses-isolated talonavicular, talonavicular and calcaneocuboid
arthrodesis, triple arthrodesis, and isolated subtalar arthrodesis,
isolated medial column arthrodesis(Greisberg et al.)
STAGE IV • Orthotic treatment
• Arthrodeses- ankle/tibiotalocalcaneal/triple
• Ankle arthroplasty - if hindfoot deformity can be corrected
• Minimally invasive deltoid ligament recon. with triple arthrodesis
However it needs to be remembered that the procedures may need to be combined as situation demands

SUMMARY..
Pes planus is the presentation of various pathologies in foot that lead to alteration medial
longitudinal arch support.
Most important thing in evaluating a case of pes planus is finding 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.

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