Pes Planus Flashcards
define pes planus
a low arched foot
does pes planus mean a pronated foot
no
considerations for differential diagnosis of pes planus
- age
- rigidity
describe flexible pediatric pes planus
- pronation
- Talipes calcaneal valgus
- ligamentous laxity
describe rigid pediatric pes planus
- congenital convex pes valgus
- tarsal coalition
describe flexible adult pes planus
- pronation
- PTTD (early stage)
- convex pes planovalgus
describe rigid adult pes planus
- Charcto Neuroarthropathy
- PTTD (later stages)
- degenerative joint disease
Primary Etiologies of pes planus
- Musculoskeletal (biomechanic deformities)
- Neurological (ie. PL spastic flat foot, cerebral palsy)
- Vascular (ie. loss of blood flow to PT)
- Metabolic (ie. Diabetes, gout)
- Trauma (ie. Trauma to nerve, tendon)
- Congential
- Infectious (ie. Syphilis)
biomechanical etiologoes of pes planus
- FF varus
- Compensated RF varus
- Dorsiflexed 1st ray
- Flexible FF valgus
- Equinus
- Limb length discrepancy (unilateral flat foot)
general clinical findings associated with pes planus
- everted calcaneus (particularly when assocaited with pronation)
- decreased medial arch
- FF abducted on RF (when associated with pronation; will see too many toe signs)
normal STJ axis has the —- and —- plane deviations approximately equal
transverse
frontal
normal OMJA axis has the — and — planes approximately equal
sagittal
transverse
radiographic finding of pes planus
- cyma line anteriorly displaced (sign of pronation)
- increased talar declination angle
- pseudo sinus tarsi
why do children have flat feet
-infants have increase subcutaenous fat, including the medial arch area which gives an appearance of a decreased medial arch
according to Valmassy what happens to the calcaneus as children being to walk
the everted position of the calcaneus decreased by 1’ with each year of age to reach rectus by age 8
Talipes calcaneovalgus
- flexible pediatric flatfoot
- congenital and apparent at birth
- lack of ankle joint plantarflexion
- may be a positional deformity, “intrauterine molding”
- may be associated with other deformities (including about 5% associated with congenital hip dislocation)
clinical appearance Talipes Calcaneovalgus
- usually recognized at birth
- Rearfoot in calcaneus position (with inability to plantarflex the ankle joint)
- Pronated subtalar joint (everted rearfoot)
- Possibly subluxed midtarsal joint (dorsiflexed and abducted)
- Skin over the anterolateral aspect of the ankle joint may develop a deep crease
treatment of Talipes Calcaneovalgus
- includes stretching/manipulation and serial casting aimed at bringing the ankle joint out of the dorsiflexed position and the calcaneus out of the valgus position
- lack of treatment may result in significant, symptomatic flatfoot
Ligamentous Laxity
- may be an isolated finding
- may be associated with other diseases and/or deformities (ie. Ehler’s Dnlos syndrome, trisomy 21 etc.)
- may be asymptomatic or symptoms associated with pronation
5 signs of ligamentous laxity
Hyperflexion at the wrist/thumb Hyperextension at the elbow Genu recurvatum Flexible flatfoot Increased flexibility as indicated by placing palms of hands on floor with knees straight
Treatment for Ligamentous Laxity
- biomechanical control/ medial arch support
- avoid activities that require functioning at end range of motion
what can cause a rigid pediatric flatfoot
- congenital convex pes valgus
- tarsal coalition
congenital convex pes valgus aka
congenital vertical talus
what is congenital convex pes valgus
- this deformity is usually recognized at birth and is often associated with other deformities
- it may appear similarly to talipes calcaneovalgus except that rigidity is the key point
- may have a rocker bottom appearance
etiologies of congenital convex pes valgus
- developmental anomaly - may be associated with decreased amniotic fluid
- genetic basis - may be associated with various trisomy syndromes
- hereditary - may be familial
- neuromuscular imbalance
- neurological states
clinical features of congenital convex pes valgus
- triplane foot deformity
- marked by abduction and dorsiflexion of the FF to the RF, equinus of the RF but the dorsum of the foot may be touching the anterior leg
clinical features of congentital convex pes valgus
Rocker bottom
Talar head is prominent medially with hyperkeratosis plantarly at the talar head
Deep skin crease on the dorsolateral aspect of the foot just anterior to the lateral malleolus
Stiff legged gait with apparent loss of equilibrium
Negative calcaneal inclination angle
Dorsiflexed and laterally deviated FF
what is the key clinical feature of congenital convex pes valgus
talonavicular dislocation with the navicular resting on the dorsal neck of the talus
treatment of the congenital convex pes valgus
- initially conservative to stretch the soft tissues
- will eventually require surgical treatment which will include soft tissue releases and realignment of the talonavicular joint or fusions
define tarsal coalition
- a congenital deformity in which there is an abnormal union between 2 bones
- an abnormal union between tarsal bones
types of tarsal coalitions are defined by
- location
- type of union
location of tarsal coalitions
- intra-articular (a true coalition)
- extra-articular (maybe be referred to as a bar of a bridge)
tarsal coalition unions
- synostosis - a bony union
- synchondrosis - a cartilaginous union
- syndesmosis - a fibrous union
what are the most common tarsal coalition locations
- STJ coalition
- calcaneonavicular coalition
- talonavicular coalition (much less common that the other two)
signs and symptoms of a syndesmosis and synchondrosis
-may allow some motion which may be more likley to cause pain
signs and symptoms of tarsal coalition (based on unions)
May become stiff and symptomatic:
- talonavicular coalition at 3-5 y/o
- calcaneonavicular at 8-12 y/o
- STJ at 12-16 y/o
signs and symptoms of tarsal coalition
- pain with STJ ROM
- marked decrease in STJ ROM (if < 10’ total STJ ROM)
clinical signs and symptoms of tarsal coalition
- may be in a fixed valgus position with peroneal spasm (guarding) causing pain up the lateral aspect of the leg
- patient may also complain of chronic ankle sprains
- compensatory and or arthritic pain (leg, knee, 1st MPJ)
Radiographic findings of Tarsal Coalition
- signs of pronation on a lateral view
- talar beaking
- halo effect
- broadening and flattening of the lateral process of the talus
- possible ball and socket ankle joint
Treatment of Tarsal Coalition
- release of the spasm/gaurding
- injection
- immobilization
- orthotic control (pronated device, UCBL)
- surgical treatment (resections, isolated function, triple arthrodesis)
how do you distinguish between an adult flexible and rigid flatfoot
Hubscher’s maneuver or Jack test
Charcot Neuroarthropahy is associated with what other disease that involve peripheral neuropathy
Diabetes mellitus (most common now) Leprosy Syphilis Alcoholism Dietary neuropathy
how many stages of Charcto foot are there
3 stages
describe stage 1 of Charcot foot
clinically, increased skin temperature, edema, may look like infection
More commonly painless
Increased blood flow to the bones
describe stage 2 of Charcot Foot
The increased blood flow causes the bone to “washed out” and softened leading to deformity
describe stage 3 of Charcot Foot
Once the active stage is over the bone is remodeled
As a result of the bony collapse, various different types of deformities may occur, with a rocker bottom flatfoot being one of the most common.
Not always rigid
Treatment of Charcot Neuroarthropathy
For the earlier stages, non-weight bearing
For residual deformity, accommodation
Orthoses (Shoe modifications, Custom molded shoes)
degenerative joint disease is a result of
almost anything!
treatment of DJD
limit motion
