A SEMINAR ON ARCHES OF FOOT AND ITS RELATED DISORDERS

PRESENTED BY DR. BHARAT DURGIA PG, ORTHOPAEDICS GMCH

MODERATOR DR. K. C. SAIKIA PROFESSOR, ORTHOPAEDICS GMCH

DATE: 23RD DECEMBER09.

ANATOMY OF FOOT
28 bones including 2 sesamoids.
14 phalanges 5 metatarsals 7 tarsals

JOINTS OF THE FOOT

anatomy contd

THE FOOT
pliable platform to support the body weight lever to propel the body forward

The ligamentous bony arrangement of the foot allows considerable flexibility/deformation with weight bearing contact

ARCHES OF FOOT

ARCHES OF FOOT
Distinctive feature in man Present since birth Segmented

Provides concavity

CLASSIFICATION OF ARCHES

LONGITUDINAL ARCH
formed between posterior end of calcaneus and head of the metatarsals highest on the medial side MEDIAL LONG. ARCH lowest on lateral side LATERAL LONG. ARCH

TRANSVERSE ARCH
highest in a coronal plane that cuts through the head of the talus

disappears near the heads of the metatarsals

FORMATION OF THE ARCHES

MEDIAL LONGITUDINAL ARCH

Ends- anterior end is formed by the heads of the 1st ,2nd & 3rd metatarsals. posterior end is formed by the medial tubercle of the calcaneum.

Summit- superior surface of body of the talus. Pillars- The anterior pillar - formed by the talus, the navicular, the 3 cuneiform and the 1st three metatarsal bones. The posterior pillarformed by the medial part of calcaneum. Joint- talocalcaneonavicular joint.

LATERAL LONGITUDINAL ARCH

Ends- anterior by the head of 4th and 5th metatarsal bone & posterior by the lateral tubercle of the calcaneum Summit- at the level of the articular facets on the superior surface of the calcaneum Pillars- anterior by the cuboid and 4th and 5th metatarsals. The posterior pillar by the lateral half of the calcaneum.

Joint- calcaneocuboid joint,

LATERAL LONGITUDINAL ARCH

characteristically low and has limited mobility built to transmit weight and thrust on the ground thereby helping in balancing act.

contd

TRANSVERSE ARCHES
ANTERIOR TRANSVERSE ARCH formed by the head of the five metatarsal bones. complete arch

POSTERIOR TRANSVERSE ARCH formed by the greater part of the tarsus and metatarsus. incomplete

MAINTENANCE OF ARCHES

FACTORS RESPONSIBLE
Bony factors Important for the posterior transverse arch Intersegmental ties-(Ligaments /muscles) The spring ligament-for medial longitudinal arch. The long and short planter ligament-for the lateral longitudinal arch. Interosseous muscle-for transverse arch.

FACTORS RESPONSIBLE
Tie beams-(Bowstrings) It connect the two end of the arch. Longitudinal arch- the planter Aponeurosis. The muscles of the first layer of sole. Transverse archadductor hallucis muscle. Slings They keep the summit of the arch pulled up.

contd.

THE LONGITUDINAL ARCH

The medial longitudinal arch is pulled upward by the tendons of the posterior compartment of the leg to the sole. The lateral longitudinal arch by the peroneus longus and peroneus brevis. The tendon of tibialis anterior and peroneus longus together form a sling ( or stirrup) which keeps the middle of the foot upward.

The transverse arch

Maintained by Peroneus longus tendon as it passes across the sole it pulls the medial and the lateral margin of the sole together. Tibialis posterior also supports the transverse arch which grips many of the bones of the sole through its slips.

FUNCTION OF THE ARCHES OF FOOT

distribute the body weight to mainly the heel and the toes. act like a spring great help in walking and running. act as shock absorbers in stepping and jumping. protect the soft tissues of the sole.

MOVEMENTS OF THE FOOT

Dorsiflexion-25* Planterflexion-35* Pronation (eversion plus abduction) -5* Supination (inversion plus adduction) -20*

BIOMECHANICS OF THE ARCHES

mechanical stable six legged stool like structure 1/3rd of the subtalar joint range is available for pronation and 2/3rd for supination. For weight bearing no muscle activity to maintain the posture

Functions as one link in a biomechanical kinetic chain

stance phase of the gait cycle risk to musculoskeletal integrity

WINDLASS MECHANICS
Engineering concept Windlass mechanics are absolutely essential for correct foot function

coordinated action of the layers of muscle, tendon, ligament and bony architecture, to maintain arch height and foot rigidity. 1st metatarsal must be allowed to planterflex

DISORDERS RELATED TO ARCHES OF FOOT

PES PLANUS
pes planovalgus, fallen arches, flat feet or pronation of feet.

loss of normal medial longitudinal arch

flexible or rigid talonavicular subluxation throughout stance phase is a major biomechanical consequence higher incidence of low back pain

Pes planus contd..

FLEXIBLE FLAT FOOT

the arch is normal when unloaded however with loading the arch is lost.

This is the most common type.

It is due to inadequate passive arch support (weak, loose ligaments).

Flexible Flat Foot

Congenital conditions1. idiopathic calcaneovalgus deformity Hyperpronation 3. 3. 4. 5. accessory navicular Marfans syndrome fragile X syndrome

Pes planus contd.. Acquired conditions1. 2. rheumatoid arthritis plantar fascia rupture tibialis posterior rupture

2.

Pes planus contd..

RIGID/FIXED/SPASTIC FLAT FOOT

the arch is absent regardless of loading an acceptable medial longitudinal arch does not appear with weight bearing may be due to a congenital deformity

Pes planus contd.

RIGID/FIXED/SPASTIC FLAT FOOT

Congenital causes 1. congenital vertical talus Acquired causes 1. osteochondral fracture

2. tarsal coaliation
3. calcaneovalgus deformity 4. equinovalgus deformity

2. juvenile rheumatoid arthritis

3. reactive peroneal spasm from fracture or chronic joint disease.

5. accessory navicular

AFFECTS OF FLAT FOOT ON SUBTALAR JOINT

with foot eversion, the calcaneus no longer supports the head of the talus, which deviates medially and plantar ward, dropping into the medial aspect of the foot arch becomes less pronounced

axis of subtalar joint becomes more horizontal more inversion and eversion
the longitudinal axis is moved more medially (than the normal 23 deg .) more dorsiflexion and plantar flexion this change in the sub-talar axis greater relative inversion-eversion and dorsiflexion and plantar flexion

pes planus contd..

CLINICAL MANIFESTATIONS
must distinguish between flexible and rigid flat foot

hyper mobile foot

forefoot varus heel cord contracture. Lateral deviation of Achilles with weight bearing; severe Achilles contracture hyperpronation of hind foot. Supination of the forefoot everted heel with fails to invert with toe raise; abducted forefoot;

pes planus contd..

X- RAYS
Standing lateral: - normal straight line relationship between talus & first metatarsal; lost - sag at either the talonavicular or naviculocuneiform joint; (Talus- 1st metatarsal angleNormal-0* Mild deformity-<15* Moderate deformity-15-30* Severe deformity->30*) Standing AP views: -degree of heel valgus -degree of talo-navicular uncoverage / subluxation;

pes planus contd..

TREATMENT
NON OPERATIVE: rarely requires treatment
main emphasis of treatment heel cord stretching SUPINATE the foot while stretching in order to "lock the midfoot in most cases orthotics are ineffective in some cases, patients with a calcaneovalgus deformity medial heel wedge can be used many feet improve as the child ages, at least until 5 to 6 yrs old, so orthotics are unnecessary in them.

OPERATIVE PROCEDURES
1. Durham flatfoot plasty (Caldwell; coleman)
Indications are flexible pes planus, failure of prolonged conservative treatment to relieve foot pain, and abnormal shoe wear. Advancement of the tibialis posterior and osteoperiosteal flap with arthrodesis of the navicular first cuneiform joint.

2. Posterior calcaneal displacement osteotomy (koutsogiannis)

in symptomatic pes planus with excessive valgus deformity. Calcaneal osteotomy is done to displace the posterior part of the calcaneum medially to restore normal weight bearing alignment.

3. Anterior lengtheningdistraction wedge osteotomy (dilwyn evans; mosca)-

Calcaneum is lengthen by inserting a corticocancellous bone graft just proximal to the calcaneocuboid joint.

4. Triple arthrodesis when the deformity becomes progressively more fixed and symptomatic after 12 years of age

5.. Kinder procedure excision of the accessory navicular and rerouting the tibialis posterior tendon into a more planter position.

CONGENITAL VERTICAL TALUS

Most common cause of rigid flat foot Rigid, rocker-bottom type of planovalgus foot, with the hind foot in equinus and the forefoot abducted and dorsiflexed axis of talus passes below the first metatarsal-cuneiform axis, and the talocalcaneal angle is >40. Associated with number of neuromuscular disorders

Cong. Vertical Talus contd

..

Pathology
detected at birth by the presence of a rounded prominence of the medial and plantar surface of the foot produced by the abnormal location of the head of the talus. talus is distorted plantarward and medially vertical the navicular lies on the dorsal aspect of the foot anterior and inferior to the lateral malleolus.

ADAPTIVE CHANGES IN TARSALS

Talus assumes shape of an hour-glass; in marked equinus position; only the posterior third of its superior articular surface articulates with the tibia. Calcaneus goes in equinus position and get displaced posteriorly, with plantar surface becoming rounded Callosities develop

With full weight is bearing, the forefoot becomes severely abducted, and the heel does not touch the floor.
Adaptive changes in soft tissue structures also

CONG. VERTICAL TALUS CONTD

CLINICAL PRESENTATION
talar head is prominent medially, convex sole, forefoot is abducted and dorsiflexed, & the hind foot is in equinovalgus;

rigid flat foot deformity

sole of foot has a rocker-bottom (convex) deformity

patient demonstrate peg-leg gait (awkward gait with limited forefoot push off);

CONG. VERTICAL TALUS CONTD..

RADIOGRAPH
PLANTAR FLEXION VIEW: (LATERAL)
In normal foot the long axis of the first metatarsal passes planter ward to the long axis of the talus. In congenital vertical talus the axis of the first metatarsal remains dorsal to the long axis of the talus, indicating dorsal dislocation of the midfoot and forefoot.

TREATMENT
NON OPERATIVE
Conservative treatment controversial

Gentle manipulation and immobilization in cast will facilitate the surgery planned for later date

OPEARTIVE OPTIONS
Age and the severity of the deformity determines the type of surgery. Child between 1-4 yrs Open reduction and realignment of the talonavicular and subtalar joint (Kumar, Cowell and Ramsay). Child with 4-8 years Open reduction and extra articular subtalar arthrodesis (Grice-green procedure) 12 years or more Triple arthrodesis Joystick method

Kumar, Cowell and Ramsay procedure

Open reduction and realignment of the talonavicular and subtalar joint

Grice-green procedure
Open reduction and extraarticular subtalar fusion

Dennyson and Fulford modification with screw fixation

Kodros and Dias Joystick method

TARSAL COALITION
failure of segmentation of the primitive mesenchyme Most common type is calcaneonavicular and talocalcaneal coalition. Calcaneonavicular coalitionages 8-12yrs; may be bony, cartilaginous or fibrous

Talocalcaneal coalition-1216yrs of age; marked reduction or absent of subtalar motion

RADIOGRAPH
for CN coalition oblique view lateral view may show talonavicular beaking talocalcaneal coalition C-sign CT-scan: -best study, especially for talocalcaneal coalition.
beaking of anterior aspect of neck of talus associated with middle facet tarsal coalition

Treatment
Initially conservative-a trial of reduced activity or cast immobilization or both is done for 4-6 weeks. Operative:-for persistent pain after conservative treatment. For talonavicular coalition: Excise coalition with wide bone block Interpose extensor digitorum brevis, gel foam or bone wax into the defect to prevent recurrence. For talocalcaneal coalition: In middle facet tarsal coalition, resection of the bar with interposition of flexor hallucis longus or gel foam or bone wax into the defect. Triple arthrodesis-in older patient with degenerative changes.

PES CAVUS
an abnormally high arch
Hyperextension of the toes at the metatarsophalangeal joints. hyper flexion of the interphalangeal joints. Pronation and adduction of the forefoot. A bony dorsum of the midfoot with wrinkled skin folds on the medial planter aspect. Lengthened lateral border and shortened medial border. Callus beneath the metatarsal head. Varied stiffness of the subtalar joint. Varus deformity of the heel. Tightness of the tendoachillis with or without equinus contracture.

ETIOLOGY
associated with neurologic disorders Exact cause can be determined by thorough history & investigations like EMG, MRI & NCV etc.

Causes are: Charcot Marie Tooth disease Poliomyelitis Spinal dysraphism Cerebral palsy Primary cerebellar disease Arthogyropsis Severe clubfoot Friedreich ataxia Post-traumatic Idiopathic

EXAMINATION
Lateral block test (Coleman and Chesnut block test ) Assesses hind foot flexibility of cavovarus foot (flexible feet correct to normal). Muscle strength and flexibility Scoliosis & thorough neurological examination.
Plantar flexed first metatarsal is allowed to hang free from block; supple hind part of foot then corrects

RADIOGRAPHS
In 1940, Brockway stated that cavus feet should never be operated upon until radiographs with the patient standing have been taken. Standing lateral view : assessment of ankle joint position, calcaneal pitch (measures the degree of Calcaneal deformity) & midfoot and forefoot position, (especially the degree of plantar flexion of the 1st ray) -x-ray of the entire spine

TREATMENT
correction of the separate components within the foot and the ankle.

CLAW FOOT
1. For fixed contracture of the MTP & IP joints Lengthening of the EDL & EHL Tenotomy of the EDB & EHB Dorsal capsulotomy of the MTP joints Resection of the head & neck of the proximal phalanges Release of the planter fascia, if indicated. Arthrodesis of the IP joints of the hallux with temporary fixation with k-wires.

b) Modified Jones procedure for clawing of great toe Tendon suspension of the first metatarsal-the EHL tendon is attached to the neck of 1st metatarsal. IP joint arthrodesis with kwire.

FOREFOOT EQUINUS
a) Proximal metatarsal osteotomy and planter fasciotomies (Gould) Double planter fasciotomies. Closing wedge greenstick dorsal proximal metatarsal osteotomies. Jones procedure can be added. Equinus of the forefoot correction may also require the Hibbs procedure- which involves transfer of the EDL tendon to the 3rd cuneiform

Tarsometatarsal truncated wedge arthrodesis (Jahss)

Arthrodesis of all the tarsometatarsal joints planter fascia release is not recommended. Not recommended for significant cavus deformity at the midtarsal level.

MIDFOOT CAVUS
1. Anterior tarsal wedge osteotomy (Cole)
Midtarsal joints are preserved. Plantar fascial release may be required.

Disadvantage: foot is shortened, widened and thickened.

2. V-osteotomy

of the

tarsus (Japas)
no bone is excised
Proximal border of the distal fragment of the osteotomy is depressed planter ward Metatarsal head is elevated, thus correcting the deformity and lengthening the planter surface of the foot.

COMBINED CAVUS (Calcaneocavus deformity)

a) Calcaneal wedge osteotomy (Dwyer) b) Cresenteric Calcaneal osteotomy (Samilson)

CALCANEOVARUS & CAVOVARUS DEFORMITY

a) Calcaneal triplanar osteotomy with lateral ligament reconstruction Peroneus brevis tenodesis (Myerson)

b) Triple arthrodesis

SUMMARY
Arches of the foot are important in distributing the weight of the body and in the gait cycle, especially in stance phase. It acts as shock absorbers while walking and running and also protects the soft tissue of the sole.

Disorders in the arches not only produce abnormality in the foot but also in the ankle, knee, hip, and spine

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