Pes planus Flashcards
Who most likely to get it?
Women, 60th decade
What is the aetiology ?
Multi factorial- 20% report acute injury
Tendon degeneration in watershed region- zone of hypo vascularity 2-6 cm from ptt attachment to navicular
What do pt complain of?
Medial ankle/ foot pain and weakness
Progressive loss medial arch
Lateral ankle pain- subfibular impingement- late
Clinical what do you see?
Pes planus Hindfoot valgus- flexible 2, fixed 3-4 Forefoot abduction- too many toes Rom- single heel raise- only in stage 1 FIXED VS FLEXIBLE- passively correctable on plantigrade foot
Where does tibialis post originate ?
Post tibia, fibula, intetosseus membrane
Name the causes of pes planus?
CONGENTIAL- vertical talus, tarsal coalition, flexible flatfoot, accessory navicula, calcaneovalgus foot
ACQUIRED- of which most common is
Posterior tibial tendon dysfunction
Then inflammatory Arthropathy
Sero negative spondylioarthropathy
What is tibialis posterior innervation?
Post tibial n L4-5
What does tibialis posterior do after passing behind medial malleolus?
Splits into 3
Anterior- inserts navicular, medial cuneiform
Middle - inserts middle/ lat cuneiforms, cuboid mt2-5
Posterior - sustentaculum tail anteriorly
What is tibialis posterior blood supply?
Post tibial artery distally- watershed 2-6 cm between navicular and distal medial malleolus
What it is tibialis posterior function ?
Primary dynamic stabiliser of arch
Hindfoot inverter
Addicts and supinates forefoot during stance phase of gait
Secondary plantar flexor of ankle
Activation allows transverse tarsal joint to lock -> rigid lever arm for toe off phase of gait
How would you investigate pes planus?
Wb ap and lateral radiographs?
What angles would give you an idea?
Lateral talo first metatarsal angle- MEARY’s greater than 4 degrees - pes planus
Calcaneal pitch - te angle formed between the flat of the ground and the inf edge of the ground- less than 11 degrees loss in arch height - normal 12-35 degrees
What is the diff with grade 2?
Broken down into 3 subgroups
2a
2b
2c
Describe the findings amd tx of grade 2a?
Pes planus
Flexible hindfoot- <40 degrees o uncovering of talus
No able to single heel raise
X-ray arch collapse
Consx- Physio & afo- good results
Surgery - fdl transfer to navicular + medial slide Calcaneal osteotomy
Describe the findings amd tx of grade 2b?
Flexible hindfoot and pes planus
FOREFOOT ABDUCTED- > 40 degrees uncovering - too many toes
No single heel raise
Arch collapse on X-ray
Tx- consx elderly orthotics as before
S= fdl transfer + lat column lengthening +/- medial Calcaneal osteotomy
Describe the findings amd tx of grade 2c?
Pp Flexible hindfoot Forefoot abducted FIXED FOREFOOT SUPINATION if stable medial column - navicular lines up with 1st mt= cotton osteotomy + fdl transfer, lat Column lengthenin ( dorsal open wedge cut to plantar flex 1st ray + medial side of calcaneous
Describe the findings amd tx of grade 3?
FIXED RIGID HINDFOOT PP FOREFOOT ABDUCTED Pc - SEVERE SINUA TARSI PAIN X-RAY- subtalar arthritis Tx- TRIPLE ARTHRODESIS + TENDOACHILLES LENGTHENING
Describe the findings amd tx of grade 4?
Same as three but
DELTOID LIG COMPROMISE
Pc- ANKLE PAIN+ sinus TARSI pain
X-rays - TALAR TILT IN ANKLE MORTICE, subtalar oa
T - if ankle valgus flexible- triple ARTHRODESIS , TAL and deltoid reconstruction but
If ankle rigid and oa subtalar- TIBIOTALOCALANEAL ARTHRODESIS
What invokes A triple ARTHRODESIS ?
Fusion of
Subtalar
Calcaneocuboid
Talonavicular
Describe the classification of posterior tibial dysfunction and tx options ?
Stage I
Tenosynovitis I X-ray changes
Consx- wb cast 3-4 wks
Orthotics - medial heel lift, longitudinal arch support all custom
Surgery- SYNOVECTONY
