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Flatfeet
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Description:
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A
flatfoot is a subjective term that describes a foot with a decreased or absent
arch. The loss of arch is usually an inherited trait that is passed from
parents to children. There's a number of
biomechanical and developmental reasons why this occurs, but in most
cases, the condition is benign and will never have a significant
impact on that patient over the course of their lives. Occasionally
though we see specific types of flatfeet that are real trouble makers.
We can talk about those in a little more detail.
How
and why does a person get flatfeet? Those are the two important questions to ask when differentiating between
the simple (non-pathological) and the not so simple (pathological) types of flatfeet.
The most common flatfoot is a simple asymptomatic
flatfoot. This type of flatfoot is present when a child first
begins to walk. Many of the moms that come in the office joke that
their child has their dad's feet indicating that he also has no
arch. We don't actually inherit this type of flatfoot per say, but
we inherit bone structure and biomechanical traits that are very similar
to those of our parents. It's really no different than the way we
inherit the color of our eyes or the color of our hair. We'll walk
and move much like our parents do and if they have flatfeet we
probably will too.
Children are challenging patients to treat because they don't have the ability to express themselves and
tell you where or how they hurt. Children will give us indications of a problem. They'll ask to be
carried or want their legs and feet to be rubbed. A child with the
common type of flatfeet that we've already mentioned will express these complaints, particularly when they've been very active.
These symptoms are due to the mechanical inefficiency of the
flatfoot. It just takes more work to walk with a flatfoot.
Therefore, kids with flatfeet have to exert more effort during a day to
keep up with the other kids.
Although most pediatric flatfeet are
asymptomatic, there are several different types of pediatric flatfeet that can
be of significant concern. There are a number of specific congenital (from birth)
deformities that we see that result in flatfeet. One of the more
common is called a
tarsal coalition. Tarsal refers to the bones of
the rear portion of the foot and coalition refers to a bridge. What
happens in cases of tarsal coalition is that a coalition or bridge of
bone forms between two bones, limiting the range of motion of the joints
of the foot. The end result is a rigid, painful flatfoot. This is
a challenging condition to diagnosis in young children. The challenge lies in the fact
that the radiographic findings of tarsal coalition don't become evident until the late teens. Part
of the diagnostic challenge lies in the fact that the bridge of bone in
young children is made of fibrous material and cannot be seen on
x-ray. As the patient matures, the fibrous bridge begins to ossify
(turn to bone). As this ossification progresses, the foot becomes
markedly rigid and painful.
The adult flatfoot can have
many of the same problems that we've already discussed in
children. The majority of adults with flatfeet simply complain of fatigue and an
inability to get through the day comfortably. These are the same
kids that we've talked about, only they've grown up.
Occasionally adult patients
will develop another type of flatfoot referred to as an acquired
flatfoot. An acquired flatfoot can be due to many different reason
such as trauma, arthritis etc. Acquired flatfeet can be some of the more
difficult flatfoot cases to manage. The most
common symptomatic acquired flatfoot that I see is due to a condition
called
posterior tibial tendon dysfunction (PTTD). The posterior
tibial tendon originates beneath the calf, comes down along the inside
of the ankle and inserts into the arch. Its' primary function is to support the
height of the arch. When this tendon is damaged and becomes 'dysfunctional' the
bones and joints of the arch begin to collapse. We'll see PTTD in many elderly
women. One day they have an arch, the next day they don't.
Treatment of Flatfeet
Treatment
of flatfeet really depends upon the symptoms that they may cause. Pain should be the
primary motivation for treatment. Obviously we start out with a
simple conservative approach in most cases.
The vast majority of
children can be treated with
arch supports and shoes. This could be
an arch support that the shoe repair shop glues into the shoe, it could
be a store bought arch support or even a custom made arch support called
an orthotic. The key is to try the simple tricks and see if they
work. How do you know that they're working? You'll simply
see a decrease in symptoms. The other consideration with kids is
that they're going to grow out of things so quickly. I think it's
money well spent to discuss your concerns with your podiatrist or
pedorthist.
They'll be able to recommend a treatment plan that may be significantly
more cost effective for your child in the long run.
Treatment of the adult
flatfoot is much the same as we've discussed with children. Try
the easy things first such as
arch supports and eurocomfort shoes.
You'd be amazed at what a decent pair of comfortable shoes can do to
change a persons life. If the symptoms of a
flatfoot don't
respond to conservative care, consult your podiatrist. I would
also like to stress that early treatment of some of the conditions that
we've discussed, like PTTD, is very important. We've
discussed the fact that PTTD is due to failure of the posterior tibial
tendon. In the early stages of this condition, the tendon is inflamed
and can be corrected. If the condition is allowed to progress, the
tendon will eventually rupture leading to a surgical correction that can
be quite extensive. Conservative care of adult flatfeet includes
traditional Oxford shoes,
arch
supports, orthotics,
OTC braces
and Rx braces.
At first
glance, flatfoot surgery would seem fairly simple; raise the arch. But in actuality
it's much more complex than that. Much of the stability of the
foot comes from the bones of the rearfoot. If a house has a bad
basement, the rest of the house is in jeopardy. The same holds
true for the foot. A faulty rearfoot jeopardizes the stability of
the rest of the foot.
In addition to correcting
the arch, we also need to consider how to restore the center of gravity
over the foot. How do we center the weight of the body over the
foot? Quite often in flatfoot cases we see the arch collapse and
the foot rolls in forcing the center of gravity to be carried somewhere
out over the inside of the foot. That's a very important
consideration when repairing flatfeet. We also discussed the
impact of a tight Achilles tendon in children and its affect on the
development of the foot. Quite often I'll lengthen the Achilles
tendon in flatfoot repair cases.
Many flatfoot correction procedures involve a
wedge resection of the arch or heel. As the wedge is closed, a new arch is
formed. Other procedures require fusion of the joint to created
needed stability. Many of these cases require prolonged casting to
allow for proper healing.
Another
type of procedure involves placing a small implant in the subtalar joint
to 'wedge' the foot and ankle into a more stable position. This procedure is referred
to as a subtalar arthroeresis (STA-Peg procedure). Arthroeresis is not as invasive as other forms
of surgical arch reconstruction, but may only be used in select cases of
flexible flatfeet. Subtalar arthroeresis is often referred to as
an internal cast, supplying support from within the subtalar joint.
The following images show the steps used to perform a STA-Peg
procedure. Image 1 shows pre-operative planning marking the boundaries of
the peroneal tendons and intermediate dorsal cutaneous nerve. In image 2
wee see the peroneal tendons retracted down and the intermediate dorsal
cutaneous nerve retracted up. Image 3 show entry into the subtalar joint.
Image 4 and 5 show preparation of the of the subtalar joint for the implant.
And image 6 shows the implant in place. The capsule of the subtalar joint
would be closed and skin reapposed with several non-absorbable sutures.
patients can bear weight on the foot the same day. STA-Peg implants come
in three sizes. Image 7 shows the implants and their corresponding
insertion/sizing tools.

Other methods employed in treating flatfeet include a procedure
called an Evans Procedure. An Evans
Procedure
is used to correct abduction of the forefoot. The test used to determine
the amount of abduction of the forefoot is called a 'too many toes sign'.
In cases of extreme forefoot abduction, when the foot is viewed from the back,
the 4th and 5th toes will be seen peeking out along the lateral aspect of the
foot. The Evans procedure is used to wedge the foot back to a straight, or
non-abducted position. An Evans procedure uses a bone graft to wedge the
distal calcaneus, in effect lengthening the lateral column of the foot. An
Evans procedure may be used in conjunction with any number of other flatfoot
procedures.
The pictures below show the steps used to perform another common
flatfoot procedure called a modified Kidner procedure. A modified Kidner
is often used in conjunction with other procedures to correct a flatfoot
deformity. A modified Kidner procedure is also used in cases of a
symptomatic os tibial externum (accessory bone of the medial arch as seen in the
image to the left).
Image 1 shows the planned approach with the leg to the left and
toes to the upper right. Image 2 shows deep tissue dissection and
identification of the posterior tibial tendon sheath. Images 3-5 show
dissection of the os tibiale externum from its' investment from within the
posterior tibial tendon. Image 6 shows repair of the posterior tibial
tendon with non-absorbable suture. Image 7 is final skin closure.
Image 8 shows the articular surface of a large os tibial externum.
Os tibiale externum is found in 15% of the general population and functions in a
way similar to your knee cap (patella), enabling its' associated muscle and
tendon to function more effectively. The os tibiale externum articulates
(forms a joint) with the navicular bone. Pain due to a symptomatic os
tibial externum is often due to arthritis at this articulation. The forceps
point to a focal area of degenerative change consistent with may be called
osteochondritis dessicans. Osteochondritis dessicans describes erosion of
cartilage that results in arthritic changes.
A modified Kidner procedure is performed on an out-patient
basis using general anesthesia and a thigh tourniquet. The
procedure takes approximately an hour to perform. Inherent in the
term modified, a modified Kidner may include several additional steps
not described in these pictures. Additional steps may include
tendon transfer or tenodesis (anchoring the tendon to the bone).
Post-op care may include a bandage, splint or cast. Some patients
may ambulate following this surgery, others may not. The size of
the os tibiale externum dictates whether a patient may walk post-op or
not. The percentage of space taken up by the os tibiale externum
within the tendon may be significant enough that immediate weight
bearing would result in failure of the posterior tibial tendon.
Your surgeon will be able to determine when you can return to ambulation
during the procedure.
The long-term success or failure of a modified Kidner procedure
can depend upon the treatment of the associated flatfoot. If the
flattening of the foot is allowed to continue following a modified Kidner,
continued stress will be placed upon the posterior tibial tendon. In some
case, this will lead to failure of the PT tendon. Therefore, it is
imperative to address the flatfoot at the time a modified Kidner is performed.
A common procedure that would accompany a modified Kidner would be subtalar
arthroeresis, medial column arthrodesis or lateral column lengthening.
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Tarsal Coalition
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Description:
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A flatfoot is simply a subjective
term that describes a foot with a decreased or absent arch. In the majority of flatfoot cases,
the primary problem is
an inherited tendency to have no arch. There's a number of
biomechanical and developmental reasons why this occurs, but in most cases, the
condition is benign and will never really have significant impact on that
patient over the course of their lives. Occasionally though we see specific
types of flatfeet that are real trouble makers. One of those conditions is
called a tarsal coalition.
There are a number of specific congenital (from birth)
deformities that we see that result in flatfeet. The most common of
these conditions is called a tarsal coalition. Tarsal refers to the bones of
the rear portion of the foot and coalition refers to a bridge. What
happens in cases of tarsal coalition is that a coalition or bridge of
bone forms between two bones, limiting the range of motion of the joints
of the foot. The end result is a rigid, painful flatfoot. This is
a challenging condition to diagnosis. The challenge lies in the fact
that the symptoms don't become evident until the late teens. Part
of the diagnostic challenge lies in the fact that the bridge of bone in
young children is made of fibrous material and cannot be seen on
x-ray. As the patient matures, the fibrous bridge begins to ossify
(turn to bone). As this ossification progresses, the foot becomes
markedly rigid and painful.
Tarsal coalitions can form at several different locations in the
foot. The most common coalition forms between the calcaneus and navicular
(shown in the x-rays on this page). The second most common coalition forms
in the subtalar joint and is subsequently called a talo-calcaneal coalition.
The third most common coalition forms at the talo-navicular joint. The
etiology of tarsal coalitions is unclear, but most clinicians assume that the
coalition forms as the result of an incomplete separation of the developing
bones while in utero.
Treatment of tarsal coalitions
The initial diagnosis of tarsal coalition is based upon clinical
findings of a fixed, rigid foot. Although X-rays don't show any specific
location of the early fibrous coalition, they do show early changes in the bone
that are secondary to the limited range of motion. These changes include
dorsal spurring of the talo-navicular joint and a halo of increased bone density
surrounding the subtalar joint. This density is one of the radiographic
signs of the early onset of osteoarthritis in the subtalar joint. A
definitive diagnosis of a tarsal coalition can be made with an MRI.
Tarsal coalitions can be managed conservatively from the onset of
symptoms until the late teens. Prescription orthotics and
bracing can
help to relieve a bit of pain but won't help to delay formation of the
coalition. The usual and customary treatment of coalitions is surgical
resection of the coalition with or without fusion of the affected joint space.
Generally speaking, calcaneo-navicular (C-N) coalition resections are quite
successful. Resection of a C-N coalition would typically be performed with
an interposition of soft tissue or muscle to inhibit regrowth of the coalition.
Talo-calcaneo coalition resections are not quite as successful as an isolated
procedure and are often performed in conjunction with a fusion of the joint
between the talus and calcaneus (subtalar joint). The determination of
whether fusion is indicated is often dictated by the amount of degenerative
change of the subtalar joint seen during the surgery.
At what age should a tarsal coalition be corrected? From one
perspective, the earlier the better is true. If a tarsal coalition is
allowed to remain unaddressed, the foot will become rigid and progressively
undergo adaptive change during the second and third decades of the patient's
life. These changes will become fixed and can only be repaired with a
salvage fusion procedure called a triple arthrodesis. But it's also
important to allow for skeletal maturity. Most children reach skeletal
maturity between the ages of 16 and 19 years old. Therefore, the best time
for correction of a tarsal coalition is between 16-19 years of age.
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Arch Pain
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Description:
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The
arch of the foot is a complex weight bearing structure that accepts load and
transfers that load with each step. The arch can adapt to uneven terrain
and provide shock absorption with each step. The arch consists of a number
of bones called tarsal and metatarsal bones. The tarsal bones are strong
load bearing bones that interlock like a jigsaw puzzle. Motion in the arch
is accomplished in a series of joints called the midtarsal joint.
The following is a list of common arch conditions. To
find more information about these conditions, follow the highlighted link.
Anterior tarsal tunnel syndrome - achy pain on the top of the foot,
aggravated by the compression of the shoes.
Arthritis of the foot - a diffuse enlargement of the top of the foot in the
elderly signals diffuse osteoarthritis of the arch.
CT
Band Syndrome - the way that the calf delivers load to the arch can
significantly affect arch pain.
Cuboid syndrome - the humble cuboid bears significant load and can cause
lateral foot pain when overused.
Flatfeet
- flatfeet can be due to a number of reasons but can often cause arch pain.
Gout -
although more common in the forefoot, gout should be considered in the
differential diagnosis of arch pain.
Peroneal tendonitis - sharp pain on the lateral foot at the onset of
activity.
Posterior tibial tendonitis - achy pain in the medial arch.
Stress fracture - midtarsal and metatarsal stress fractures are often the
cause of nonspecific arch pain.
Tarsal coalition - stiffening of the arch with the onset of symptoms in the
early late second decade or early third decade of life.
Tarsal tunnel syndrome - an entrapment of the posterior tibial nerve with
pain that radiates into the arch.
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