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Pes Planus

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17 views

Pes Planus

Uploaded by

hacker ammer
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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*Flat foot (pes planus)

*Pes cavus (high medial arch of the foot)

*Rheumatoid arthritis of the ankle and foot

*Ruptured tendo Achillis

Dr. Mahmoud Kh.yaseen


Flat foot ( pes planus or Pes Planovalgus):
• It’s the condition where there is :
• flattening of the medial longitudinal arch of the foot, its usually associated
• valgus hindfoot (flat everted foot).

• Incidence
• unknown in pediatric population
• 20% to 25% in adults
• Pathoanatomy
• generalized ligamentous laxity is common
• 25% are associated with gastrocnemius-soleus contracture
Classification
1. Hypermobile flexible pes planovalgus (most common)
• familial
• associated with generalized ligamentous laxity and lower extremity
rotational problem
• usually bilateral
• associated with an accessory navicular
• correlation is controversial
2. Flexible pes planovalgus with a tight heel cord
3. Rigid flatfoot & tarsal coalition (least common)
• no correction of hindfoot valgus with toe standing due limited
subtalar motion
Presentation of flexible type
• Symptoms
• usually asymptomatic in children
• may have arch pain or pretibial pain

• Physical exam
• inspection
• foot is only flat with standing and reconstitutes with toe walking, hallux dorsiflexion, or foot
hanging
• valgus hindfoot deformity
• forefoot abduction
• motion
• normal and painless subtalar motion
• hindfoot valgus corrects to a varus position with toe standing
• evaluate for decreased dorsiflexion and tight heel cord
Presentation of rigid type
• History
• history of prior recurrent ankle sprains
• Symptoms
• asymptomatic
• most coalitions are found incidentally
• 75% of people are asymptomatic
• pain
• location of pain
• sinus tarsi and inferior fibula suggests calcaneonavicular
• distal to medial malleolus or medial foot suggests talocalcaneal
• pain worsened by activity
• onset of symptoms correlates with age of ossification of coalition
• calf pain
• secondary to peroneal spasticity
• Physical exam (rigid)
• inspection
• hindfoot valgus
• forefoot abduction
• pes planus
• range of motion
• limited subtalar motion
• heel cord contractures
• arch of foot does not reconstitute upon toe-standing
• hindfoot remains in valgus (does not swing into varus) upon toe-standing

• special tests
• Coleman block test
• evaluate for subtalar rigidity
Treatment
Flexible
• Nonoperative
• observation, stretching, shoewear modification, orthotics
• indications
• asymptomatic patients, as it almost always resolves spontaneously
• counsel parents that arch will redevelop with age
• Achilles tendon or gastrocnemius fascia lengthening
• indications
• flexible flatfoot with a tight heelcord with painful symptoms refractory to stretching
Rigid
• immobilization with casting, analgesics
• indications
• initial treatment for symptomatic cases
• techniques
• below-knee walking cast for six-weeks
• outcomes
• up to 30% of symptomatic patients will become pain-free with a short period of immobilization

• Operative
• coalition resection with interposition graft, +/- correction of associated foot
deformity
• indications
• persistent symptoms despite nonoperative management
• Arthrodesis
• in sever cases
Pes cavus (increased or high medial arch of the foot):
• The medial arch is higher than normal
• varus foot and finger clawing

the main Causes are:


• Primary : idiopathic, usually familial and bilateral.
• Secondary : Neuromuscular conditions like cerebral palsy, peroneal muscle dystrophy
or friedreich’s ataxia

This deformity of the foot with the clawing of the toes puts the body weight on the
metatarsal heads that projects down into the sole of the foot and usually there is an
overlying skin callosities due to friction with the shoe.
 In the mobile flexible early deformity the foot shape can be restored if the metatarsal
heads pushed up by the examiner’s finger, as the arch gets normal and the clawing of
the toes corrected. Later the deformity if untreated gets fixed and painful.
• In standing lateral views, some measurements are useful in describing
the type of high-arched foot:
• (a) the axes of the talus and first metatarsal are parallel in normal feet but cross
each other in a plantaris deformity (Meary’s angle);
• (b) the calcaneal pitch is greater than 30 degrees in calcaneus deformities
Treatment:
• In cases of painless mobile deformity
• no treatment is needed apart from special shoe wear.

• In severe deformities which is still mobile


• the foot shape can be improved and weight bearing on metatarsal heads can be decreased
by rebalancing surgery correcting the clawing by tendon transfer so the long toe flexors are
released and transferred from the planter to the dorsal aspect of the toes and fixed on the
extensor expansion so it will correct the hyperextension and put the toes straight.

• For fixed deformities no much can be done, if special shoe wear is not enough
complex bone surgeries and arthrodesis can be done, operations must always
delayed after the age of 16 years.
Rheumatoid arthritis of the ankle and foot:
• The foot is affected as common as the hand and the disease pass in its three
stages,
• 1st. stage of synovitis that affects ankle, intertarsal and other small joints, also
affects synovial tendon sheath of different tendons mainly the tibialis posterior
and the peronei.

• 2nd .stage of erosion of the articular cartilage and tendons that can be torn.

• 3rd. stage of severe deformity and dysfunction with the characteristic


deformities of foot valgus, forefoot splaying, hallux valgus and toe clawing.
• There will be alot of planter callosities and dorsal corns that may get inflamed or infected
and sometimes ulcerate.
• Clinically:
• Patient having progressive pain and discomfort with difficulties in shoe wear and walking.
• There is limitation of movements and gradual development of deformities,
• callosities and corns.
• X-ray: May show the joint erosions and foot deformities.
• Treatment:
• Special care for shoe wear, rest, and limitation of weight bearing sometimes by special
weight relieving calipers.
• Drug treatment according to the stage of the disease like NSAID, painkillers, disease
modifying drugs.. .etc.
• Local steroid injection of joints or around tendon sheaths whenever indicated.
• Synovectomy of joints or tendon sheaths.
• For seriously deformed foot replacement arthroplasty or joint arthrodesis.
Ruptured tendo Achillis
• Probably rupture occurs only if the tendon is degenerated.
• Consequently most patients are over 40.
• While pushing off (running or jumping), the calf muscle contracts; but the
contraction is resisted by body weight and the tendon ruptures.
Presntation
• The patient feels as if he has been struck just above the heel, and he is
unable to tiptoe.
• Soon after the tear occurs, a gap can he seen and felt 5 cm above the
insertion of the tendon. Plantar flexion of the foot is weak and is not
accompanied by tautening of the tendon.
• Where doubt exists, Simmonds’ test is helpful: with the patient prone and foot
free out of bed, the calf is squeezed; if the tendon is intact, the foot is seen to
go into planti-flexion; if the tendon is ruptured the foot is still without any
movement.
Treatment:

• If the patient is seen early, the ends of the tendon may be approximate when
the foot is passively plantiflexed. If so, plaster is applied with the foot in
equinus and is worn for 8 weeks. A shoe with a raised heel is worn for a
further 6 weeks.
• Operative repair is probably safer, but an equinus plaster for 8 weeks and a
heel raise for a further 6 weeks are still needed.

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