Management of Flatfoot The Best Foot Forward

Dr. Shah Alam KhanMS,DNB,MRCS(Ed),FRCS, M.Ch.Orth (Liverpool)

Associate ProfessorDepartment of Orthopedics

All India Institute of Medical ScienceNew Delhi, INDIA

Issues

• Define Flat-foot• Clinical Features• Investigations• Treatment Indications• Treatment Options

Definition

• No Universally accepted Radiological or Clinical definition

• Lateral Talus–First metatarsal angle (Meary's angle)

Grading

Denis Grading- Objective Evaluation

Denis A. Pied plat valgus statique. Encyclopedie Medico-Chirurgicale AppareilLocomoteur. Paris, France: Editions Techniques; 1974

Clinical Features

• Depressed longitudinal arch in 23% of the adult population (Harris R, Beath T: Army Foot Survey: An Investigation of Foot Ailments in Canadian soldiers, Ottawa: National Research Council of Canada; 1947:1)

• Prevalence of flat feet in Children 4-13 yrs was 2.7% (Rodriguez et al, Paediatrics, 1999)

• Only 5 to 10% of Adult & Pediatric flatfoot need Active treatment (Smith MA. Flat feet in children. Br Med J. 1990;301:1331)

Clinical Features

• Cosmesis (in about 40% children)

• Pain (25-30%)• Early Fatigue (15-25)• Awkward Gait (5%)• Frequent Falls (3%)• Quick Shoe Wearing

off (2-5%)

Flexibility

Passive Extension of Great Toe should have two effects for a POSITIVE test:1.Elevation of

Longitudinal Arch2.Lateral Tibial

Rotation

Great Toe Extension Test

Rose et al . The diagnosis of flat foot in a child. JBJS Br. Vol. 67-B. No. I. Jan 1985

Examination

• Particular attention to TA

• Check Dorsiflexion of Ankle

• Evaluate the torsional Profile of the limbs

• Foot Callosities

Examination

Complete Neurological Assessment:

• Weakness (poliomyelitis, peripheral neuropathy)

• Weakness with Achilles tendon contracture (Duchenne's muscular dystrophy)

• Spasticity with equinus (cerebral palsy)

Examination

• Stiff Hindfoot• Rule out a Tarsal

Coalition• Rigid Rocker Bottom

Deformity (Congenital Vertical

Talus)

Investigations

Rationale:• No need to investigate

EVERY child• Rule out SINISTER causes• To look for a TREATABLE

cause

Radiography• Foot (AP, 45 deg Int Obl) • Ankle (AP, Lateral)• Rule out Tarsal

Coalition/CVT• Evaluate the Meary’s Angle

Bohne WH. Tarsal coalition. Curr Opin Pediatr. 2001 Feb;13(1):29-35

CT Scan

• Best to evaluate a bony coalition

• Weight Bearing CT in Flexible flat-feet (Fore foot Arch Angle)

Ferri et al. Weightbearing CT scan of severe flexible pes planus deformities. Foot Ankle Int. 2008 Feb;29(2):199-204

Podography

• Static & Dynamic Foot prints

• Pressure Mat (conventional)

• Computerised

Podography

• Shape of the Heel and its relation to the other toes

• Areas of High pressure under great toe, Ist MT and Medial side of Heel

Is it Rigid or Flexible Flat foot?

Are there any other causes of

this condition?

Risk Factors in Flexible Flat foot

• Obesity• Ligamentous Laxity• Rotational Deformities of Knee• Tibia vara• Tarsal Coalition• Short Tendo Achilles

Napolitano et al. Risk factors that may adversely modify the natural history of the pediatric pronated foot. Clin Podiatr Med Surg. 2000 Jul;17(3):397-417

Treatment

AbstentionistsInterventionists

Vs

Treatment Protocols

• No treatment in 95-97%• Some treatment in 3-5%• Surgery in around 2% children (Sullivan. Pediatric flatfoot: evaluation and management J Am Acad Orthop Surg.1999; 7: 44-53 )

• Treat symptomatic pediatric flatfoot• Monitor (or with discretion simply treat) asymptomatic non-

developmental pediatric flatfoot• Identify asymptomatic developmental pediatric flatfoot

Angela Margaret Evans. The Flat footed child-to treat or not to treat. J Am Podiatric Med Assoc.2008: Vol98; 7: 386-89)

Conservative Treatment

• Observant Neglect (children with risk factors)

• Counseling the Parents• ?Foot Exercises• ??Orthosis• Pain Management

Intrinsic Foot Exercises

• Passive stretching of Great toe & TA

• No conclusive evidence that Intrinsic foot exercises help

• Build up of muscles useful in Maintaining an arch

Insoles

Insoles

• Known to cause stimulation of foot muscles (Tib Post)

• Supports the Medial Ligamentous complex

• Helpful before 3yrs of age• Volumes of Literature

available

Bordelon RL. Hypermobile flatfoot in children. Comprehension, evaluation, and treatment. Clin Orthop Relat Res. 1983 Dec;(181):7-14

Modified UCBL shoe insert significantly

reduced the degree and duration of

abnormal pronation during the stance

phase and thus had the potential for

decreasing strain in the plantar

ligaments

(Leung AK et al. Biomedical gait evaluation of the immediate effect of

orthotic treatment for flexible flat foot. Prosthet Orthot Int. 1998

Apr;22(1):25-34)

We concluded that wearing

corrective shoes or inserts

for three years does not

influence the course of

flexible flatfoot in children.

(Wenger et al. Corrective shoes and inserts as treatment for flexible

flatfoot in infants and children. J Bone Joint Surg Am. 1989

Jul;71(6):800-10)

Arch alignment improved

significantly but to a limited

degree (<2%) in cadaveric feet

with the use of orthoses. Hindfoot

valgus malalignment did not

consistently improve by the use

of shoe inserts.(Kitaoka et al. Effects of foot orthosis on 3D Kinematics of flatfoot- A

cadaveric study. Arch Phys Med Rehabil 2002 Jun;83(6):876-9)

Indications for Surgery

• Failure of Conservative Methods & Pt Symptomatic

• NEVER for Cosmetic Reason• Symptomatic Flat foot interfering

with daily ADL• Flat foot with a cause (Accessory

Navicular, CP, Tarsal Coalition)

Principles of Surgery in Flat foot

Crego and Ford1. Any procedure for flatfoot correction should be done for

disabling pain2. Not be done for cosmetic reasons only3. Surgeon, Patient & the parents must be able to accept some

loss of inversion and eversion of the foot in exchange for pain relief

4. Arthrodesis for relieving painful flatfoot has been most successful when the subtalar joint is included

5. Triple arthrodesis is recommended for the skeletally mature flatfoot

Surgical Procedures in Flat foot

Surgical procedures can be classified as follows :• Medial soft tissue + bony procedure• Calcaneal procedures• Arthrodesis• Arthroereisis

MEDIAL PROCEDURES

• Raising of osteoperiosteal flap based at the sustentaculum tali

• Arthrodesis of the first metatarsal- medial cuneiform and first cuneiform- navicular joint

• Advancement of osteoperiosteal flap beneath insertion of tibialis anterior tendon

Surgically Correctible Flatfoot

Equino-valgus foot ofCerebral Palsy

Surgically Correctible Flatfoot

Surgically Correctible Flatfoot

Painful Rigid Flatfoot:• Subtalar Fusion (before mid

foot breaks)• Grice Green Procedure (less

than 10 years)• Triple Arthrodesis (Age> 10 yrs)

Surgically Correctible Flatfoot

Painful Flexible Flatfoot:• Determine the anatomic

cause of the pain• Lateral Column Lengthening• Calcaneal Osteotomy• Lengthening of a short TA• Distraction calcaneo-cuboid

arthrodesis

Calcaneo-valgus deformity. D. Evans. JBJS. Vol 57-B. 1975. p 270-278

Surgically Correctible Flatfoot

Excision of Calcaneo-navicular Bar

Take Home Message

• Evaluation of Flat foot in Children requires Skill & Care

• Great Toe Extension test determines the Flexibility of Flatfoot

• Flexible Flat feet in almost all children require Conservative treatment

• Role of Insoles is doubtful

Take Home Message

• Before adventing on Surgical intervention remember to rule out other causes

• Surgical Treatment is limited for few

BIO LOGICAL Treatment of Flat foot