Pes Cavus and Pes Planus

Moderator:PROF.DR.K.PRAKASAM

M.S.Ortho,D.Ortho,DSc(HON)

Director&HOD

Presentor:Dr.Thouseef A Majeed

ANATOMY OF THE ARCHES OF FOOT

A) Two longitudinal arches

– Medial longitudinal arch

– Lateral longitudinal arch B) Transverse arch

• Anterior transverse arch• Posterior transverse arch

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

Medial longitudinal arch

• Higher than lateral

• Composed of – Calcaneous

- Talus

- Navicular

- 3 cuneiform

- 3 metatarsals

• Talar head is key stone of this arch

• Tibialis anterior attached to – 1st metatarsal,medial cuneiform

– strength for this arch.

• Peroneus longus tendon – pass laterally to this arch providing

support

Lateral longitudinal Arch• Flatter than medial longitudinal arch.• Rests on the ground during standing.• It is made up of – calcaneous, cuboid, 2 lateral

metatarsals.

Transverse arch • Runs from side to side• It is formed by – cuboid,

cuneiforms, bases of metatarsals

• Medial and lateral parts of longitudinal arch act as pillars

• Tendons of fibularis longus and tibialis posterior

Integrity of bony arches

• Maintained by passive factors and dynamic supports

Passive factors• Shape of the united bones • Four successive layers of fibrous

tissue – bowstring the longitudinal arch

– Plantar aponeurosis

– Long plantar ligament

– Plantar calcaneocuboid (short

plantar) ligament

– Plantar calcaneonavicular

(spring) ligament

Dynamic supports

• Active bracing action of intrinsic muscles of foot

• Active and tonic contraction of muscles with long

tendons extending in to foot

– Flexor hallusis and digitorum longus – longitudinal arch

– Fibularis longus and tibialis posterior – transverse arch• Plantar ligaments and plantar aponeurosis bear

greatest stress and important in maintaining arches

MECHANISM OF ARCH SUPPORTSHAPE OF BONES

• Bones are wedge-shaped with the thin edge lying inferiorly

• This applies particularly to the bone occupying the center of

the arch“keystone”

MECHANISM OF ARCH SUPPORTSUSPENDING THE ARCH FROM ABOVE

• Medial longtitudinal arch: Tibialis anterior, Tibialis

posterior, medial ligament of ankle joint

• Lateral longtitudinal arch: Peroneus longus, Peroneus

brevis

• Transverse arch: Peroneus longus

MECHANISM OF ARCH SUPPORTSUSPENDING THE ARCH FROM ABOVE

PES CAVUS

Synonyms for Cavus Foot

• Schaffer Foot

• Lotus Flower Foot

• Bolt Foot

• Claw Foot

• Vault Foot

• Hollow Foot

• Anterior Equinus

• Pes Cavo Varus

• Contracted Foot

• Talipes (Pes)

Arcuatus

• Talipes Plantaris

Defenition

• Cavus is an acquired or congenital deformity

of the foot ,characterized by excessive high

longitudinal plantar arch combined with

clawing of the toes .

Etiology Neurological Causes

• Charcot Marie Tooth disease

• Friedrich’s Ataxia

• Roussy-Levy syndrome

• Poliomyelitis

• Cerebral Palsy

Congenital– Spina Bifida

– Talipes Equinovarus

– Myelodysplasia

– ClubfootIatrogenic

– Post surgery or trauma

– Peroneal nerve injury

Etiology

Infection– Syphillis

– Poliomyelitis

Idiopathic– Most common

Development of the deformity• The intrinsic musculature

normally flexes the

metatarsophalyngeal joint

and extends the

interphalyngeal joint.

• When the long flexor contracts on the straight digit it slings

up the heads of the metatarsals and prevents the drop of the

forefoot on the hind foot

• In the absence of lumbricals ,the long flexor pulls the toes

into flexion and no longer supports the metatarsal head.

• So the forefoot drops and the lax structures in the sole

contracts and forms claw foot.

• Dropping of fore foot on the hind foot followed by a

contracture of the plantar fascia and clawing of the

toes

CLINICAL FEATURES

• High arch.

• Hyper extension of toes at

metatarso-phalyngeal joint

• Hyper flexion at the inter-

phalyngeal joints.

• Pronation and adduction of the

fore foot .

• Lengthened lateral border of foot

and shortened medal border.

• Callosities beneath the metatarsal

heads

• A bony dorsum of mid-foot with

wrinkled skin folds on the medial

plantar aspect

Radiographic findings –pes cavus

Standing weight bearing Antero –posterior and Lateral views

X Rays taken to

• Demonstrate the apex of the deformity

• Talo calcaneal ankle

• Calcaneal pitch

• Degree of plantar flexion of the great toe

• Asess the contribution of cavus by hind foot,midfoot and

fore foot

DEGREES OF PES CAVUS

• 5 degrees

First degree pes cavus

• Child is clumsy with repeated falls

• Foot appears normal

• Deformity appears when foot is relaxed

• Child catches his toes against low objects such as edges of

carpet.

• Mild extensor weakness

Treatment of first degree pes cavus

• Daily manipulation –supinating fore foot and everting heel

• Anterior arch bar in shoes

• If not corrected then Girdle stone tendon transfer

operation.

• Through an incision on each toe

extending distally from metatarso-

phalyngeal joint .

• Long and short toe flexors are brought

to lateral aspect of proximal phalynx

and sutured to the extensor expansion.

Second degree pes cavus• Flexion of the fore foot

• Plantar fascia is felt to be tense and contracted

• Clawing of great toe .

• Great toe clawing can be corrected by upward pressure on

the ball of great toe.

Treatment of second degree Pes cavus

• A shoe fitted with a metatarsal bar may give temporary

relief.

• Stiendlers Procedure : Plantar fascia release

• Jones Procedure:The Extensor hallucis longus tendon is

divided at its insertion and passed though the neck of first

metatarsal + Interphalyngeal joint fusion.

Third degree pes cavus

• The arches of foot is markedly raised.

• All toes are clawed .

• Tendocalcaneus may begin to appear contracted.

• Painfull callosities are seen.

• Deformities are rigid and cannot be corrected by finger

pressure under Ist metatarsal head

Treatment of third degree Pes cavus

• Stiendlers procedure +Muscle sliding

operation.

• Japas ‘ V‘osteotomy of tarsus : Apex of V is

proximal and highest point of cavus

• Dwayers Calcaneal Ostetomy

Fourth degree pes cavus

• In addition to cavus and claw toes

• Adduction at tarsometatarsal joints resulting in varus

deformity.

• Rigid and painful foot

• Walking becomes painful and difficult.

Fifth degree-pes cavus

• Seen on paralytic conditions.(poliomyelitis)

• Whole foot is contracted into rigid equino varus with high

arch.

• Tender callosities.

• The patient is very disabled .

Treatment of fourth and fifth degree Pes cavus

• Dunns triple arthrodesis

• Lambrinudis arthrodesis

(triple arthrodesis :subtalar+calcneo cuboid +talo

navicular joint fusion)

• Cols Anterior tarsal wedge osteotomy

PES-PLANUS

Synonyms

• Pes planovalgus

• Flat feet

• Fallen arches

• Pronation of feet

Definition

• Absence of normal medial longitudinal arch

• Instep of the foot collapses and comes in

contact with the ground.

• In some individuals, this arch never develops

Other abnormalities• Heel valgus

• Mild subluxation of subtalar joint(talus tilts medially and

plantarwards)

• Eversion of the calcaneus at the subtalar joint

• Lateral angulation of midtarsal joints (Talo

Calcaneal ,Calcaneo Cuboid)

• Supination of forefeet

• Flat feet are a common condition.

• In infants and toddlers, the longitudinal arch is not

developed and flat feet are normal.

• The arch develops in childhood

• By adulthood (12-13yrs), most people have

developed normal arches

Types

Flexible Can be Rigid painless Painful

Types

• Flexible –on weight bearing it disappears and

on non weight bearing it reappears

• Rigid – acceptable medial longitudinal arch

does not seen even on non weight bearing

• Flexible, painless is most common

Etiology

FlexibleDevelopmental – the most common

Hypermobile (ligamentous hyperlaxity; Ehlers-Donlos, Marfans)

Neurogenic( rare and usually cause the reverse-Pes Cavus)

Rigid Congenital (Tarsal coalition,Vertical talus)

Aquired ) inflammatory)

SYMPTOMS

Deformity

• Foot pain ,ankle pain, leg pain

• Heel tilts away from the midline of the body more than

usual

• Abnormal shoe wear

FLAT FEET CAN produce• Tendonitis. posterior tibial tendon and it can either fail,

rupture, stretch or just hurt. This condition is called

POSTERIOR TIBIAL DYSFUNCTION (PTD OR TPD) .

• Arthritis.

• Plantar fasciitis

• Bunions & Hammertoes

• Corns and callosities

Radiography

• Asymptomatic flatfoot radiological evaluation unnecessary

• First Antero posterior and Lateral views of the foot should

be taken to evaluate severity of deformity

• Antero-posterior ankle to rule out valgus at the distal end of

tibia

• Special view - 45 degree eversion oblique for accessory

navicular bone

Radiography • AP standing view is to asses heel valgus , Talocalcaneal

angle more than 35 degree is associated with incresed heel

valgus

• CT scan accurately defines anatomy of subtalar joint ,

allows surgical plannig if it is involved.

Meary’s Angle• Most common angle to indicate

flat foot

• Intersects at apex of the

deformity

• Meary’s angle - between long

axis of talus and long axis of

first metatarsal on a standing

lateral X ray

Normal Meary's angle:long axis

of the talus should bisect the

navicular and first metatarsal

0 degrees – normal

0 – 15 degrees – mild

15 – 40 degrees – moderate

> 40 degrees – severe

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

Treatment

0-3 years old:

No treatment unless very strong family hx of persistent

flatfeet

Orthotic shoes with thomas heels ,medial heel wedges and

navicular pads

Convince the parents.

Treatment

3-9 years

• Conservative management

• No surgery

• Custom orthosis inserted with leather ,cork,

propylene .

Treatment

• 10-14 yrs

• No symptom- No treatment

• Symptomatic – conservative management

initially

• Surgical

Surgical treatment

Indications

1.pain

2.failure to respond to orthotic control

3.Ulceration or callus under the head of the plantiflexed talus

4.Excessive shoe wear

Surgical treatment

• The surgeon , patient, and parents must be willing to

exchange loss of eversion and inversion of the foot

for relief of pain and disability .

Surgical treatment

• Arthrodesis for relieving painful flat foot have been

most successful when the subtalar joint is involved .

• Although midtarsal arthtrodesis without inclusion of

the subtalar joint has gained popularity

Surgeries

• Durham flatfoot plasty

• Posterior calcaneal displacement osteotomy

• Anterior calcaneal lengthening – distraction

wedge osteotomy

• Triple atrhrodesis (triplane)

Durham plasty for pes planusA, Incision.

B, Elevation of posterior tibial

tendon.

C, Elevation of osteo-periosteal

flap from proximal to distal.

D, Arthrodesis of navicular–first

cuneiform joint.

E, Extent of arthrodesis resection

through midfoot.

F, Internal fixation of navicular–

first cuneiform joint.

•

pull the posterior tibial tendon taut

into its prepared bed on the

plantar surface of the waist of the

navicular, and tie the suture

dorsally

Calcaneal osteotomy (Dilwyn-Evana,Mosca)

• Lengthening of lateral

column of the foot by

inserting a tibial bone graft

and calcaneocuboidal

fusion

Posterior calcaneal displacement osteotomy(koutsgiannis)

• Symptomatic patients with excessive heel valgus , a

calcaneal osteotomy is intended to displace the

posterior part of the calcaneum medially , to restore

normal Weight bearing alignment

Triple Arthrodesis

Joints fused are:

• Subtalar joint

• Calcaneo cuboid joint

• Talo navicular joint

AGE

• Usually done after the age of 12

• Triple arthrodesis tend to have a high (50%) failure rate in

children under 10 years of age;

• contra-indicated in young children (less than 10-12 yrs)

because the procedure limits foot growth

Complications

• Nonunion

• Degenerative joint disease

• Avascular necrosis

• Lateral instability

• Stiff foot

Accessory navicular bone

• It is a most common accessory bone in the foot

• Listed as a cause of flat foot

Pathoanatomy

• Abnormal insertion of Tibialis Posterior into

accessory navicular bone believe to cause the flat

foot

Clinical presntation

• Often incidental, many patients are asymptomatic

• Pain

• Prominence of medial aspect of foot

• On attempted inversion of the foot against resistance

, Tibialis posterior tendon is inserted into the bump

and this maneuver produces pain

Radiography

• Special view - 45 degree eversion oblique for

accessory navicular bone

• Antero-Posterior view and Lateral weight bearing

views of the foot should be taken to evaluate other

deformities

Radiological types • TypeI–Small ossicle in the substance of Tibialis Posterior

tendon (os tibiale externum or naviculam secondorium )

• Type II –Triangular frangment larger than type I connected

to navicular bone by a cartilaginous synchondrosis

• Type III – Cornuate navicular resulting from fusion of the

accessory navicular with main body of navicular

Treatment

INITIAL TREATMENT –

Conservative- stretcing shoes, avoiding activity

that irritates foot

SURGICAL-

Kidners procedure

Kidners procedure

• Excision of accessory navicular bone and rerouting of

Tibialis Posterior tendon into a more plantar position

• Parents should be informed before surgery that pain

may not be alleviated completely

“Our feet are no more alike than our faces”

THANK YOU