Pathomechanics & Conservative

care:Adult Acquired

Flat Foot

Dr.Rajiv ShahFoot & Ankle Surgeon

‘Foot & Ankle Orthopaedics’Vadodara, Surat, Gujarat

2

Tibialis PosteriorMedial arch

stabilizers

3

Why TP is at risk of rupture/tendinosis?

14mm zone of

ischemia due to lack of mesotenon

Acute curve at medial malleolus

Shallow malleolar groove

Compression & constriction under Flexor retinaculum

TP dysfunction: pathophysiology

Repetitive micro

trauma

Tendon & sheath

inflammation

Tendon elongation

Tendon rupture

AAFD: pathophysiology

Ruptured TP

Failed medial restrains = Flat foot

No locking of TT joints +

unopposed pull of peroneus brevis everts heel =

Heel valgus

The longitudinal axis of 1st metatarsal and talus forms zero degree angle-Meary’s angle

Weight bearing biomechanics

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

Weight bearing biomechanics

Calcaneum also plantarflexes and plantar fascia is stretched to limit arch collapse

Weight bearing biomechanics

Navicular and cuneiform dorsiflex, evert & abductwhich is limited by TP

Weight bearing biomechanics

Metatarsals also dorsiflex and abduct

Weight bearing biomechanics

Final picture on weight bearing

Weight bearing biomechanics

Midfoot bones and metatarsals dorsiflex & abduct & flatfoot results

If these restraints fail, then???Talus plantarflexes - moves distally and rotates medially

Calcaneum planterflexes & goes in valgus

Weak spring lig & ITCL fails to support

Clinical Stages

Stage 1TendinopathyNormal tendon lengthNo 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

Clinical testsSingle Limb Heel Raise Test

Too many toes signHeel ValgusTP function evaluation

Weight bearing X-rays Lateral View: break in Talo-1st MT line

(Meary’s Line) Altered talar declination angle

NormalAcquired Flatfoot

Radiological diagnosis

Normal

Flat foot

AP View: talo-navicular uncoverage Forefoot abduction

Radiological diagnosis

Normal < 7 degree

AAFD > 7 degree

Stage 2a

Less than 30% medial talar head uncoverage (or no lateral incongruence)

No clinical forefoot abduction

More than 30% medial talar head uncoverage or lateral incongruence

Significant clinical forefoot abduction

Stage 2b

Lateral Incongruence

Congruent 2a

Incongruent 2b

Arthritis of subtalar, TN & CC joints Forefoot abduction Heel valgus

Radiological diagnosis: Stage 3Radiological diagnosis: Stage 4

Tendon pathology, tear, degeneration

Spring ligament visualization

Usually not necessary

Magical effect

MRI???

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

NSAIDS

Conservative care: Modalities

Management of systemic disease

Physical therapyStrengthening

TherabandIontophoresisCryotherapy

OrthoticsMedial wedgeMedial column

postHeel alterations

UCBLFoot moldBK cast

Boot

Activity modification

That’s all…Thank you all..

IFFASCON- 15 at Ludhiana August 28th, 29th & 30th, 2015

20 international faculties

Day 1: Parekh family foundation workshop (7 modules)

Day2 & 3: ConfenrenceA must attend meeting for 2015!