Flatfoot- Feilmeyer

Question 1

What are some associated symptoms with being flat footed?

Answer 1

pain in:
arch, heel, achilles, medial ankle. knee, lateral hindfoot/ankle
*** some may say- no pain, just looks funny.

Question 2

some other pearls of wisdome from MF….

Answer 2

make sure you understand biomechanics of pronation to understand the stresses flatfeet put on overall lower limb
*make sure to look at surrounding structures. solely defining one problem region and trying to fix it individually will not totally address the issue. ( e.g. equinas and bunions)MAKE SURE TO LOOK OUTSIDE THE ISSUE

Question 3

what brings a patient in aside from pain?

Answer 3

feet look funny, run funny, run heavy foot/flatfooted, decreased activity/participation of child.

Question 4

lessons on getting fooled with the Hx patient gives…

Answer 4

they could blame their issue on an ankle sprain, but we must look outside of that. evaluate them beyond ankle sprain, as if that wasnt mentioned.

Question 5

some aspects of flat feet?

Answer 5

collapsed arch
medal ankle and knee pain
medial ankle has stretched ligaments
lateral ankle has complexes that might be pinched ( sometimes pain more lateral than medial)
( all in all, this goes back to biomechanics… not an ankle sprain the patient may have reported)

Question 6

what is flat foot a result of?

Answer 6

external rotation of the hip. another example of looking at the biomechanic big picture.

Question 7

some things to check out with a physical exam…generals

Answer 7

neurovascular
pain
muscle strength
reducible/non reducible
ankle joint ROM ( smooth or is there a catch)
equinas ( if so- this changes the biomechanics of everything)
STJ ROM
gait exam
WB position

Question 8

what do the XR show?

Answer 8

• lacking arch
• calcaneus should be angled upwards
• bones are slanting downward
• we see the foot abducted with a “positive line sign”
• in “regular” non pathologic flatfoot, we should see the joints lined up ( talonavicular)

Question 9

more specifics on what the XR show…AP and lateral views.

Answer 9

AP: increased forefoot abduction
increased talar head uncovering
increased talo-2nd metatarsal angle

Lateral: anterior break in the cyma line
decreased calcaneal inclincation angle
increased talar declinaton angle
midfoot breach.

*** tid-bit: we also see calcaneal cuboid joint starts to break down. as well as talonavicular. this is wear and tear due to the bio mechanical issue. if in flatfoot position for 30+ years- joints will def be affected

Question 10

what are some of our conservative treatment options?

Answer 10

1. orthotics ( controls overpronation, however difficult to control transverse plane deformity… it can help preserve joints)
2. stretching ( minimal long term benefit)
   Physical Therapy

• ** these all have limited long term benefit if pathologic flatfoot and associated with equinas.
• – make sure to discuss these options first no matter what!!

Question 11

why does pathologic flat foot require more invasive measures?

Answer 11

due to association with equinas…

DJD ( degenerative joint disease) and chronic changes to bone and tendon will occur if not addressed EARLY.

Question 12

so how about that surgical intervention…what are we gonna do?

Answer 12

1. address equinas ( if you dont, the flat foot will return)
2. calcaneal osteotomies ( Evans or calcaneal slide)
3. midfoot osteotomies ( cotton- medial cuneiform, is there is bunion deformity…)
4. Tendon transfers ( tighten up the lax tendons on medial side, so sometimes replace them)
5. tarsal implant ( new procedure. middle ground- they dont fix the problem, essentially put plug in to stop the talus from rotating medially…debated procedure due to potential to cause inflammation and dislodge or be rejected)

*** less invasive the better, however oftentimes dont fix the actual issue. so we gotta get out our big guns.

Question 13

what is an Evans procedure?

Answer 13

*lengthens lateral column
- gastroc lengthened
-relocates TN joint
*improves peroneus longus function ( ligament)
moves the effective STJ axis laterally
-medializes achilles
-reduces valgus heel
-increased calcaneal inclination

*** brings the ankle out more laterally see slides for photos.. causes ankle to supinate. helps line up the joints. once you change one joint, make sure you compensate for how the others may have changed.

Question 14

why should we fixate the osteotomy?

Answer 14

1. loss of lateral column ( this was our primary correction, try to reduce graft collapse, or calcaneal collapse)
2. shift of anterior fragment
3. stability ( improves early active ROM)

Question 15

what is this business about a locking plate?

Answer 15

Less displacement observed with locking plate. as well as less shift observed. this is a good thing!!!

Question 16

what is the fixated technique? locking plate vs screw?

Answer 16

osteotomy with graft that is secured with locking plate. this is was not done previously.

plate: load bearing bridge fixation- the ideal mechanics for inter-positional bone graft. also allows for multi-planar stability
screw: does not neutralize angular or compressive forces on the bone.