1. Dr.Rajiv Shah
Foot & Ankle Surgeon
‘Foot & Ankle Orthopaedics’
Vadodara, Surat, Gujarat

2. 2
Tibialis Posterior

3. 3
 14mm zone of
ischemia due to
lack of mesotenon
 Acute curve at
medial malleolus
 Shallow malleolar
groove
 Compression &
constriction under
Flexor retinaculum

4. Repetitive
micro trauma
Tendon &
sheath
inflammation
Tendon
elongation
Tendon
rupture

5. Ruptured
TP
Failed medial
restrains =
Flat foot
No locking ofTT joints +
unopposed pull of
peroneus brevis everts
heel = Heel valgus

6. The longitudinal axis of 1st metatarsal and
talus forms zero degree angle-Meary’s angle
Weight bearing biomechanics

7. On weight bearing talus plantarflexes and slides
distally on Calcaneum, which is restrained by spring
ligament
Weight bearing biomechanics

8. Calcaneum also plantarflexes and plantar fascia is
stretched to limit arch collapse
Weight bearing biomechanics

9. Navicular and cuneiform dorsiflex, evert & abduct
which is limited byTP
Weight bearing biomechanics

10. Metatarsals also dorsiflex and abduct
Weight bearing biomechanics

11. Final picture on weight bearing
Weight bearing biomechanics

12. Midfoot bones and metatarsals dorsiflex & abduct & flatfoot
results
Talus plantarflexes - moves distally and rotates medially
Calcaneum planterflexes & goes in valgus
Weak spring lig & ITCL fails to support

13. Clinical Stages
Stage 1
Tendinopathy
Normal tendon
length
No deformity
Stage 2
 Tendon
lengthening
 Flexible
deformity
Stage 3
 Tendon
lengthening
 Fixed
deformity
Stage 4
 Fixed
deformity
 Talus tilted in
ankle(ankle
involvement
 Dereymaeker:
Stage Zero
 Biomechanical
abnormality
 No symptoms
 Stage 2: 2a & 2b
 2a: Medial
symptoms
 2b: Lateral
symptoms

14. Clinical tests
Single Limb Heel RaiseTestToo many toes signHeelValgusTP function evaluation

15. Weight bearing X-rays
 LateralView: break inTalo-1st MT line
(Meary’s Line)
 Altered talar declination angle
Normal
Acquired Flatfoot
Radiological diagnosis
Normal Flat foot

16.  APView: talo-navicular uncoverage
 Forefoot abduction
Radiological diagnosis
Normal < 7 degree AAFD > 7 degree

17.  Less than 30% medial talar head
uncoverage (or no lateral
incongruence)
 No clinical forefoot abduction

18.  More than 30% medial talar head
uncoverage or lateral incongruence
 Significant clinical forefoot abduction

19. Congruent 2a Incongruent 2b

20. Arthritis of subtalar,TN & CC joints
Forefoot abduction
Heel valgus
Radiological diagnosis: Stage 3Radiological diagnosis: Stage 4

21.  Tendon
pathology, tear,
degeneration
 Spring ligament
visualization
 Usually not
necessary
 Magical effect
MRI???

22.  Stage 1: essentially
conservative
 Stage 2: conservative
care for at least 6
months or more
 Stage 3 & stage 4:
patients with co-
morbid conditions &
unfit for surgery
Conservative care
 Stage 1: prevent
tendon rupture by
giving rest to tendon
 Stage 2:prevent
progression of
deformity
 Stage 3 & stage 4:
accommodation of
deformity

23. NSAIDS
Conservative care: Modalities
Management of
systemic disease
Physical therapy
Strengthening
Theraband
Iontophoresis
Cryotherapy
Orthotics
Medial wedge
Medial column
post
Heel alterations
UCBL
Foot mold
BK cast
Boot
Activity modification

29. That’s all…
Thank you all..

30.  August 28th, 29th & 30th, 2015
 20 international faculties
 Day 1: Parekh family foundation
workshop (7 modules)
 Day2 & 3: Confenrence
A must attend meeting for 2015!