eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Pes Planus: Workup

Author: Matthew Buchanan, MD, Attending Surgeon, Orthopedic Foot and Ankle Surgery, Orthopaedic Foot and Ankle Center of Washington, DC
Coauthor(s): Gregory C Berlet, MD, FRCS(C), Clinical Assistant Professor of Orthopedics, Chief of Foot and Ankle Surgery, Department of Orthopedic Surgery, Ohio State University College of Medicine and Public Health; Abdi Raissi, MD, Staff Physician, Desert Orthopaedic Center
Contributor Information and Disclosures

Updated: Feb 27, 2009

Workup

Imaging Studies

As with most foot and ankle deformities, weight-bearing radiographs are mandatory.31 The authors' protocol includes 3 weight-bearing views for the foot (anteroposterior [AP], oblique, and lateral) and 3 weight-bearing views for the ankle (AP, mortise, and lateral).

Evaluation of longitudinal arch collapse is largely dependent upon weight-bearing lateral radiographs. The axis of the talar-first metatarsal angle on the lateral weight-bearing foot radiograph is the most discriminating radiographic parameter in patients with symptomatic flatfoot.32  Alternatively, the distance between the medial cuneiform and the floor is a strong reflection of medial arch collapse and flatfoot.33   Additional features of flatfoot deformity that are noted on the lateral view include talar plantar flexion and decreased calcaneal pitch.23

An AP standing foot projection is primarily used for evaluating talar head uncoverage secondary to lateral deviation of the navicular. As peritalar lateral subluxation increases, the talonavicular coverage angle—created by 2 reference lines through the centers of the talar head and navicular bone, respectively—reveals increased angles.

Standing AP radiographs of the ankle are evaluated for evidence of valgus talar tilt with resultant subluxation, arthrosis, or both. The ankle view is particularly important in patients who have fixed hindfoot valgus. Hindfoot alignment can be further evaluated in the axial plane with the so-called Buck view, as described in a 1995 study by Saltzman and el-Khoury.26 The lateral tibial-calcaneal angle as measured on a standing lateral ankle x-ray identifies patients with Achilles tendon contractures.34,35

Although highly dependent on technique and experience of the interpreter, magnetic resonance imaging (MRI) can be extremely sensitive and specific in the evaluation of adult-acquired flatfoot deformity (AAFD); MRIs provide highly detailed evaluations of both the bony and soft-tissue anatomy. In most instances, however, posterior tibial tendon (PTT) dysfunction can be adequately diagnosed with a thorough physical and radiographic examination. Because of the expense of MRI, a cost-to-benefit ratio should be evaluated; most MRI examinations should be reserved for patients who have a confusing clinical picture.

Determining the amount of joint degeneration with computed tomography (CT) scanning in patients who have chronic disease may be beneficial; however, this modality does not provide comprehensive information on tendon pathology. In patients with late-stage AAFD and lateral hindfoot pain, CT scans may show 2 frequently occurring extra-articular sources of bone impingement (sinus tarsi and calcaneofibular impingement).36

Staging

The severity of adult-acquired flatfoot deformity (AAFD) varies, depending upon the degree of pathologic anatomy and the resultant changes in biomechanics. Therefore, staging the spectrum of dysfunction can be extremely helpful in guiding treatment protocols. In their 1989 report, Johnson and Strom described an initial 3-stage continuum of posterior tibial tendon (PTT) dysfunction.10

  • Initial stage 1 findings include mild tenderness along the inframalleolar course of the PTT, with minimal (if any) loss in tendon strength as assessed by the single-limb, heel-rise test. When the patient bears weight only on the involved extremity, performing the heel-rise test demonstrates not only adequate strength but also initiation of heel inversion, which signals an intact tendon. The foot and ankle typically demonstrate normal alignment without fixed deformity.3
  • The key to diagnosis of stage 2 disease is a dynamic deformity, typically hindfoot valgus with forefoot abduction. Palpation along the course of the PTT demonstrates pain and possibly hypertrophy and/or defects. Observing the patient's stance from behind reveals increased visualization of the lateral toes (too-many-toes sign) on the affected extremity secondary to weakness.9 Single-limb heel rise may not be possible due to weakness, and if performed, corrective heel inversion is generally absent. With the exception of possible gastrocsoleus contracture, hindfoot and midfoot motion testing usually yield normal results.
  • As the continuum of disease progresses to stage 3, chronic dysfunction and lengthening of the PTT lead to fixed hindfoot deformity. In order to achieve a plantigrade foot in the setting of a fixed hindfoot valgus, the forefoot typically compensates into a fixed supination position. With stage 3 disease, patients often present with lateral pain secondary to subfibular impingement as the calcaneus subluxes and the flatfoot deformity progresses.3,37
  • In 1997, Myerson added a fourth stage to Johnson and Strom's original description of PTT dysfunction.11 Long-standing hindfoot valgus places increasing stress on the deltoid complex, with eventual loss of competence. The resultant valgus tilt of the talus leads to eccentric loading of the ankle with subsequent tibiotalar arthrosis.23,37

More on Pes Planus

Overview: Pes Planus
Workup: Pes Planus
Treatment: Pes Planus
Follow-up: Pes Planus
Multimedia: Pes Planus
References
Further Reading
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References

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Keywords

pes planus, acquired flatfoot, adult-acquired flatfoot deformity, AAFD, progressive flatfoot deformity, posterior tibial tendon dysfunction, PTTD, posterior tibial tendon insufficiency, PTTI, fallen arches, posterior tibial tendon, PTT, talipes planus, flat foot, flatfoot, splayfoot, pes planovalgus, spring ligament complex, spring-ligament complex, too many toes sign, too-many-toes sign, plantar fasciitis, cri-du-chat, plantar heel pain

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Contributor Information and Disclosures

Author

Matthew Buchanan, MD, Attending Surgeon, Orthopedic Foot and Ankle Surgery, Orthopaedic Foot and Ankle Center of Washington, DC
Matthew Buchanan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Foot and Ankle Society
Disclosure: Nothing to disclose.

Coauthor(s)

Gregory C Berlet, MD, FRCS(C), Clinical Assistant Professor of Orthopedics, Chief of Foot and Ankle Surgery, Department of Orthopedic Surgery, Ohio State University College of Medicine and Public Health
Gregory C Berlet, MD, FRCS(C) is a member of the following medical societies: American Medical Association, American Orthopaedic Foot and Ankle Society, Canadian Medical Association, Canadian Orthopaedic Association, College of Physicians and Surgeons of Ontario, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Abdi Raissi, MD, Staff Physician, Desert Orthopaedic Center
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. Luke's 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: Nothing to disclose.

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, FAAOS, Chairman, J Vernon Luck Distinguished Professor, Department of Orthopedic Surgery, University of Missouri
Jason H Calhoun, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, and American Orthopaedic Foot and Ankle Society
Disclosure: Nothing to disclose.

 
 
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