eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Acquired Flatfoot: Workup

Author: R Todd Hockenbury, MD, Clinical Assistant Professor, Department of Orthopedic Surgery, University of Louisville
Contributor Information and Disclosures

Updated: Apr 23, 2009

Workup

Laboratory Studies

  • Generally, no laboratory studies are warranted for adult acquired flatfoot unless a systemic metabolic or inflammatory condition is suspected.
  • A painless, atraumatic flatfoot deformity in an insensate foot is most likely due to neuroarthropathy (Charcot foot). The most common cause of neuroarthropathy in the United States is diabetes. If diabetes mellitus is not already diagnosed, a fasting blood glucose test is indicated.
  • If the patient has pain in multiple joints, consider a workup for rheumatoid arthritis or seronegative spondyloarthropathy with rheumatoid factor, erythrocyte sedimentation rate, and HLA-B27.

Imaging Studies

  • Radiography
    • Standing anteroposterior and lateral radiographs of the foot and ankle should be obtained.
    • Measurements of the lateral first talometatarsal angle, calcaneal pitch, distance from medial cuneiform base to the floor, and talonavicular coverage angle are made.
    • As a flatfoot deformity develops, the arch sags at the naviculocuneiform or talonavicular joint, causing a decrease in calcaneal pitch, a decreased lateral first talometatarsal angle, and depression of medial cuneiform height (see Image 4).
    • The forefoot moves laterally into abduction, causing lateral subluxation of the talonavicular joint and an increase in the talonavicular coverage angle (see Image 5).
    • Standing ankle views are mandatory to exclude ankle valgus instability as a contributing factor to the heel valgus and pes planus deformity.
Standing lateral radiograph of the foot of a pati...

Standing lateral radiograph of the foot of a patient with posterior tibial tendon (PTT) dysfunction. A, Lateral first talometatarsal angle (normal value 0°). B, Calcaneal pitch (normal value, 20-25°). C, Distance from medial cuneiform to floor (normal value varies with foot size). As deformity increases secondary to posterior tibial tendon dysfunction, the talus plantarflexes and the medial border of the foot is lowered. Therefore, the lateral first talometatarsal angle decreases, the calcaneal pitch decreases, and the medial cuneiform is depressed closer to the floor.

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Standing lateral radiograph of the foot of a pati...

Standing lateral radiograph of the foot of a patient with posterior tibial tendon (PTT) dysfunction. A, Lateral first talometatarsal angle (normal value 0°). B, Calcaneal pitch (normal value, 20-25°). C, Distance from medial cuneiform to floor (normal value varies with foot size). As deformity increases secondary to posterior tibial tendon dysfunction, the talus plantarflexes and the medial border of the foot is lowered. Therefore, the lateral first talometatarsal angle decreases, the calcaneal pitch decreases, and the medial cuneiform is depressed closer to the floor.


Standing anteroposterior radiograph of a patient ...

Standing anteroposterior radiograph of a patient with posterior tibial tendon (PTT) dysfunction shows the talonavicular coverage angle; the navicular axis is formed by a perpendicular to a line connecting the medial and lateral aspects of the navicular proximal articular surface. The talonavicular coverage angle is formed by the talar and navicular axes. As forefoot abduction increases, the talonavicular coverage angle increases.

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Standing anteroposterior radiograph of a patient ...

Standing anteroposterior radiograph of a patient with posterior tibial tendon (PTT) dysfunction shows the talonavicular coverage angle; the navicular axis is formed by a perpendicular to a line connecting the medial and lateral aspects of the navicular proximal articular surface. The talonavicular coverage angle is formed by the talar and navicular axes. As forefoot abduction increases, the talonavicular coverage angle increases.

  • Tenography
    • Tenography has been used to diagnose posterior tibial tendon rupture with limited success.
    • For this test, 5 mL of radiopaque dye is injected into the sheath between the medial malleolus and navicular tuberosity. In later stages of dysfunction, the tendon and sheath become adherent, and injection of dye becomes impossible. Following tendon rupture, the sheath often is not palpable, and injection is very difficult.
    • In 1 study, tenography was successfully performed in only 1 of 6 patients.
  • Magnetic resonance imaging
    • MRI is helpful in diagnosing posterior tibial tendon dysfunction, but it is not required to make the diagnosis.
    • Conti et al used MRI to describe 3 types of posterior tibial tendon degeneration. A type I finding is a partially torn tendon with tendon enlargement and vertical splits. Type II is a partially torn attenuated tendon. A type III finding is a complete rupture with a tendon gap.13
    • Although it is sensitive, MRI can cause overestimation of the degree of tendon degeneration based on surgical findings, with a mere 40% correlation between MRI and surgical findings. This MRI classification is useful in predicting the outcome of tendon transfer, with higher grades of tendon degeneration faring worse than mild grades of degeneration.

Staging

Johnson and Strom described 4 stages of posterior tibial tendon dysfunction.14 These stages are used to dictate treatment.

  • Stage 1 is characterized by peritendinitis and tendon degeneration, but the tendon length remains normal. This stage presents clinically as pain and swelling along the posterior tibial tendon sheath.
  • In Stage 2, the posterior tibial tendon elongates, and a supple flat foot deformity develops. Although deformed on weight bearing, the hindfoot and midfoot deformities are passively correctable to neutral.
  • Stage 3 occurs over time as the hindfoot becomes rigid in a valgus position, and the patient develops a rigid flatfoot deformity.
  • Stage 4 develops as the deltoid ligament becomes incompetent and the talus tilts into valgus within the ankle mortise.

More on Acquired Flatfoot

Overview: Acquired Flatfoot
Workup: Acquired Flatfoot
Treatment: Acquired Flatfoot
Follow-up: Acquired Flatfoot
Multimedia: Acquired Flatfoot
References
Further Reading
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Keywords

flat foot, flatfoot, pes planus, acquired adult flatfoot, posterior tibial tendon dysfunction, PTT dysfunction, posterior tibial tendon insufficiency, PTT insufficiency, Chopart joint, too-many-toes sign, too many toes sign, Evans calcaneal osteotomy, Evans' calcaneal osteotomy

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Contributor Information and Disclosures

Author

R Todd Hockenbury, MD, Clinical Assistant Professor, Department of Orthopedic Surgery, University of Louisville
R Todd Hockenbury, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, and Kentucky Medical Association
Disclosure: Nothing to disclose.

Medical Editor

James K DeOrio, MD, Director of Foot and Ankle Fellowship Program, Assistant Professor of Orthopedic Surgery, Orthopedic Surgery, St Lukes Hospital, Jacksonville, Florida
James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Florida Medical Association, and German Society of Neurology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Shepard R Hurwitz, MD, Executive Director, American Board of Orthopaedic Surgery
Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS, Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center
Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association
Disclosure: Nothing to disclose.

 
 
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