logo logo
An investigation of the factors affecting flatfoot in children with delayed motor development. Chen Kun-Chung,Tung Li-Chen,Tung Chien-Hung,Yeh Chih-Jung,Yang Jeng-Feng,Wang Chun-Hou Research in developmental disabilities This study investigated the prevalence of flatfoot in children with delayed motor development and the relevant factors affecting it. In total, 121 preschool-aged children aged 3-6 with delayed motor development (male: 81; female: 40) were enrolled in the motor-developmentally delayed children group, and 4 times that number, a total of 484 children (male: 324; female: 160), of gender- and age-matched normal developmental children were used as a control group for further analyses. The age was from 3.0 to 6.9 years old for the participants. The judgment criterion of flatfoot was the Chippaux-Smirak index >62.70%, in footprint measurement. The results showed that the prevalence of flatfoot in children with motor developmental delay was higher than that in normal developmental children, approximately 58.7%, and that it decreased with age from 62.8% of 3-year-olds to 50.0% of 6-year-olds. The results also showed that motor-developmentally delayed children with flatfoot are at about 1.5 times the risk of normal developmental children (odds ratio=1.511, p=0.005). In addition, the prevalence of flatfoot is relatively higher in overweight children with delayed motor development, and that in obese children is even as high as 95.8% (23/24). Children with both excessive joint laxity and delayed development are more likely to suffer from flatfoot. The findings of this study can serve as a reference for clinical workers to deal with foot issues in children with delayed motor development. 10.1016/j.ridd.2013.12.012
Problem feet in children. Fixsen J A Journal of the Royal Society of Medicine 10.1177/014107689809100107
Foot and ankle abnormalities among a cohort of Nigerian school children: an epidemiological study. Bafor A,Chibuzom C N International orthopaedics PURPOSE:Foot and ankle problems in children are a common cause for paediatric orthopaedic referrals. There is a variation in the reported epidemiology of foot and ankle abnormalities across the globe. The prevalence in our locality was unknown. The objective of this study was to determine the prevalence pattern of foot and ankle problems in our locality as well as compare with patterns from other geographical locations to determine the presence or otherwise, of differences among varying populations. METHODS:One thousand seven hundred and fifty-eight Nigerian primary school children aged between five and 13 years were clinically evaluated, checking for weight, height and calculation of BMI. The heel axis angle and hallux angle were measured clinically while determination of flatfeet or high arched feet was made from analysis of foot imprints. RESULTS:Hindfoot valgus was the commonest abnormality of the foot and ankle in this population with a prevalence of 34.2% and predominantly in females and older children, while hallux valgus and a high arched foot were the least common abnormalities at 0.6 and 0.7% prevalence rates, respectively. We found no statistically significant relationship between BMI and hindfoot valgus. CONCLUSION:Hindfoot valgus is the commonest foot and ankle abnormality among primary school children in our locality. 10.1007/s00264-020-04568-z
Combined Subtalar and Naviculocuneiform Fusion for Treating Adult Acquired Flatfoot Deformity With Medial Arch Collapse at the Level of the Naviculocuneiform Joint. Steiner Caspar Samuel,Gilgen Andrea,Zwicky Lukas,Schweizer Christine,Ruiz Roxa,Hintermann Beat Foot & ankle international BACKGROUND::A challenge in treating acquired flatfoot deformities is the collapse of the medial arch at the level of the naviculocuneiform (NC) joint. Triple fusions, being a treatment option, may lead to problems such as increased foot stiffness. We thus established a method that combines subtalar (ST) fusion with NC fusion while preserving the Chopart joint. We analyzed the radiographic correction, fusion rate, and patient satisfaction with this procedure. METHODS::34 feet in 31 patients (female, 23; male, 8; age 67 [45-81] years) were treated with a ST and NC joint fusion. In 15 cases, a medial sliding-osteotomy was additionally necessary to fully correct hindfoot valgus. The following radiographic parameters were measured on weightbearing radiographs preoperatively and at 2 years: talo-first metatarsal angle, talocalcaneal angle, calcaneal pitch, talonavicular coverage angle and calcaneal offset. Fusion was radiologically confirmed. RESULTS::All parameters, except the calcaneal pitch, showed a significant improvement. Fusion was observed after 1 year in all but 2 cases (94.1%). One nonunion each occurred at the ST and NC joint without needing any subsequent treatment. One patient developed avascular necrosis of the lateral talus with need for total ankle replacement after 1 year. All patients were satisfied with the obtained results. CONCLUSION::Our data suggest that a combined fusion of the ST and NC joint was effective and safe when treating adult acquired flatfoot with collapse of the medial arch at the level of the NC joint. Although the talonavicular joint was not fused, its subluxation was significantly reduced. LEVEL OF EVIDENCE::Level IV, case series. 10.1177/1071100718800295
Letter to the editor on "Does the long-term use of medial arch support insole induce the radiographic structural changes for pediatric flexible flat foot? - A prospective comparative study". Liufu Shenghua,Xu Jian,Yu Yongzhuang Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons 10.1016/j.fas.2019.07.003
Tarsal tunnel syndrome in athletes. Kinoshita Mitsuo,Okuda Ryuzo,Yasuda Toshito,Abe Muneaki The American journal of sports medicine BACKGROUND:The details of the occurrence of tarsal tunnel syndrome in athletes have not been well documented in the literature, and more data on tarsal tunnel syndrome related to sporting activity are necessary to enable better recognition of this condition. HYPOTHESIS:Sporting activities make athletes vulnerable to the occurrence of tarsal tunnel syndrome under specific conditions. STUDY DESIGN:Case series; Level of evidence, 4. METHODS:Between 1986 and 2002, 18 patients with tarsal tunnel syndrome related to sporting activities were surgically treated, of whom 15 patients (21 feet; mean age, 17.8 years) were competitive athletes and 3 were recreational sports amateurs (4 feet; mean age, 52.7 years). To assess the role of physical factors and sporting activities in making athletes vulnerable to the occurrence of tarsal tunnel syndrome, the authors reviewed the medical charts and evaluated the results of treatment. The mean duration of follow-up was 58.6 months. RESULTS:Activities that triggered tarsal tunnel syndrome were those that applied a heavy burden on the ankle joint such as sprinting, jumping, and performing ashibarai in judo under specific physical conditions. Predisposing underlying physical factors were flatfoot deformity and an existence of talocalcaneal coalition, accessory muscles, and bony fragments around the tarsal tunnel. The majority of patients were able to return to the same sport after treatment. CONCLUSION:Tarsal tunnel syndrome occurs in athletes involved in strenuous sporting activities, especially when predisposing physical factors are present. 10.1177/0363546506286344
Response to "Letter Regarding: Preliminary Outcomes of Calcaneal Lengthening in Adolescent Flatfoot in Müller-Weiss Disease". Foot & ankle international 10.1177/1071100719849430
Are knee and foot orthopedic problems more disabling in the superobese? Fabris Sonia M,Faintuch Joel,Brienze Sergio L A,Brito Gilberto B,Sitta Isabela S,Mendes Estevao L P,Fonseca Ines C B,Cecconello Ivan Obesity surgery BACKGROUND:Aiming to ascertain whether frequency and severity of knee and foot problems were different between morbid obesity (MO) and superobesity (SO), a prospective clinical study was designed. METHODS:Bariatric candidates (N = 81, body mass index 40-81.3 kg/m(2), 43.2 % with SO) were submitted to knee and foot radiologic assessment, baropodometric footprint measurement, and the questionnaires Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Foot and Ankle Outcome Score (FAOS). Main outcome measures were imaging diagnosis of knee osteoarthritis and flatfoot, along with functional impact on activities of daily living estimated by the questionnaires. RESULTS:Knee osteoarthritis was radiologically diagnosed in 74.1 % (60/81), and the entire cohort suffered from flatfoot according to both footprint index and talar-first metatarsal radiographic angle; nevertheless, distribution was not different between SO and MO. However, WOMAC and FAOS scores were markedly worse in SO, affecting joint pain, stiffness, and general mobility. This is the first protocol of our knowledge to address foot and knee derangements in SO. CONCLUSIONS:Functional impairment was more severe in SO, despite a morphologic pattern similar to MO. Even though amelioration is probable with weight loss, long-term orthopedic assistance might be required in such circumstances. 10.1007/s11695-012-0778-x
Flatfoot and associated factors among Ethiopian school children aged 11 to 15 years: A school-based study. PloS one BACKGROUND:The Foot health of a child plays a pivotal role in their participation in play, locomotive activities, healthy lifestyle, somatic development, and weight management. The burden of flatfoot among children in Ethiopia is not known. The objective of this study was to analyze the structure of the medial foot arch using Staheli plantar arch index and investigate its associated factors among larger sample school children, aged 11-15 years in Ethiopia. METHODS:A school-based cross-sectional study was conducted among children aged 11-15 years from eleven randomly selected primary schools. The sample size was determined proportionally across school strength and governmental and private schools to ensure variety within the sample. Data collection consisted of physical measurements, footprint-based measures whilst full weight-bearing, and a structured questionnaire on foot pain, footwear type, and physical activity. Data were analyzed descriptively and through uni- and multivariate logistic regression model. RESULTS:A total of 823 children participated. The overall prevalence of flatfoot was 17.6% with a significant difference between age, gender, type of school, BMI, and type of footwear. Being younger (OR 3.3, 95% CI 1.6-6.7), male (OR 1.6, 95% CI 1.0-2.4), experiencing foot pain (OR 1.9, 95% CI 1.0-3.5), wearing closed shoe (OR 4.4, 95% CI 1.6-11.9), overweight (OR 3.8, 95% CI 1.2-8.7), obese (OR 4.2, 95% CI 2.5-10.9), and low level of physical activity (OR 2.1, 95% CI 1.0-4.6) were significantly associated with flatfoot. Children who were overweight, obese, and also experiencing foot pain have a 2.8 (95% CI 1.62-5.94) and 4.1 (95% CI 2.85-8.31) times greater chance of having flatfoot respectively. The prevalence of flatfoot among 560 normal weight children was 17.5%. CONCLUSIONS:The findings of this study demonstrated that the overall prevalence and the prevalence of flatfoot among normal-weight children are almost the same. There is a definite need to develop a screening algorithm for diagnosis and treatment indication for this children's lower extremity disorder. 10.1371/journal.pone.0238001
Foot typology, body weight distribution, and postural stability of adolescent elite soccer players: A 3-year longitudinal study. Marencakova Jitka,Maly Tomas,Sugimoto Dai,Gryc Tomas,Zahalka Frantisek PloS one OBJECTIVE:The unique foot morphology and distinctive functions facilitate complex tasks and strategies such as standing, walking, and running. In those weight-bearing activities, postural stability (PS) plays an important role. Correlations among foot type, PS, and other musculoskeletal problems that increase sport injury risk are known. However, long-term associations among the foot type, the PS, and body weight (BW) distribution are lacking. Thus, the purpose of this study was to longitudinally identify changes in foot morphology, PS, and symmetry in BW distribution during adolescence among elite male soccer players. METHODS:Thirty-five Czech elite male soccer players (age, 15.49 ± 0.61 years; BW, 64.11 ± 6.16 kg; body height, 174.62 ± 5.71 cm) underwent foot type, PS, and BW distribution measurements during 3 consecutive years (T1, T2, T3). The Chippaux-Smirak index (CSI), BW distribution, and centre of pressure (COP) displacement (total traveled way [TTW]) of each player for the preferred (PL) and non-preferred leg (NL) were acquired. Repeated-measures analysis of variance (RM ANOVA), Bonferroni´s post hoc tests, and partial eta-squared (ηp2) coefficient were used for investigating the effect of time on selected variables and effect size evaluation. RESULTS:Statistically significant effect of time on CSI values (PL: F2,68 = 5.08, p < 0.01, ηp2 = 0.13 and NL: F2,68 = 10.87, p < 0.01, ηp2 = 0.24) and COP displacement values (PL: F2,68 = 5.07, p <0.01, ηp2 = 0.13; NL: F2,68 = 3.53, p <0.05, ηp2 = 0.09) for both legs over 3-years period was identified. Furthermore, the Bonferroni´s post hoc analysis revealed a significant improvement of PS values in the PL (TTWT1 = 1617.11 ± 520.22 mm vs. TTWT2 = 1405.29 ± 462.76, p < 0.05; and between TTWT1 = 1617.11 ± 520.22 mm vs. TTWT3 = 1370.46 ± 373.94, p < 0.05). Only BW distribution parameter showed no significant differences, although slightly improved over time. CONCLUSIONS:We observed changes in foot typology, PS, and BW distribution in young elite male soccer players during 3 consecutive years. Results demonstrated that changes in PS and body weight distribution under the high-load sport conditions during adolescence may improve with aging, except for foot morphology. Therefore, foot morphology should be carefully monitored to minimize sport injury risk in professional young soccer players during adolescence. Further research is necessary to determine more clear associations between these parameters, soccer-related injuries, and sport performances. 10.1371/journal.pone.0204578
Tibialis posterior tendon rupture in children. Abosala Abdulbaset,Tumia Nezar,Anderson David Injury
Stability of the arch of the foot. Kitaoka H B,Ahn T K,Luo Z P,An K N Foot & ankle international We defined the relative contributions of six ligaments in stabilizing the arch of the foot: plantar aponeurosis, long-short plantar ligaments, plantar calcaneonavicular ligament (spring ligament), medial talocalcaneal ligament, talocalcaneal interosseous ligament, and tibionavicular portion of the deltoid ligament. Nineteen fresh-frozen human foot specimens were used. A load of 445 N was applied axially to simulate standing-at-ease posture. Three-dimensional positions of tarsal bones before and after ligament sectioning were determined with the use of a magnetic tracking device. The motions were presented in the form of screw axis displacements, quantitating rotation, and axis of rotation orientation. After sectioning one structure, the arch did not collapse on any specimen and there was no obvious change by visual inspection. There were, however, measurable changes in tarsal bone position. Metatarsal-to-talus total rotation difference was greatest with spring ligament and deltoid ligament sectioning, with an average of 2.1 degrees +/- 1.7 degrees and 2.0 degrees +/- 0.2 degree difference, respectively. Calcaneus-to-talus rotation difference was greatest with talocalcaneal interosseous ligament sectioning, with an average of 1.7 degrees +/- 1.5 degrees. The spring ligament, deltoid ligament, and talocalcaneal interosseous ligament were most important for arch stability. 10.1177/107110079701801008
The effects of individually designed insoles on pes planus treatment. Açak Mahmut Scientific reports The aim of this study was to examine the effects of individually designed insole in pes planus treatment. Designed insoles was adjusted according to height, length and function of the sole of each participant with pes planus in order to improve the physical parameters of them. A total of 34 participants (17 males and 17 females) with pes planus participated in the study. Height, weight, percent body fat, 30-m sprint test, vertical jump, 12-min Cooper test and Visual Analog Scale (VAS) measurement were obtained before the study and after 1 year later. Wilcoxon signed rank test was conducted to examine whether there were any differences between the pre- and post-test measurements. It was determined that individually designed insoles reduced body weight and BMI, made positive improvements in 30-m speed, vertical jump and 12-min Cooper scores, and significant decrease in VAS scores. In conclusion, it is seen that individually designed insoles have beneficial role in normalizing forces acting on the foot and improve the physical performance parameters of individuals with pes planus. Future studies are needed to explore the long-term effects of individually designed insoles and prefabricated insoles. 10.1038/s41598-020-76767-y
Peritalar destabilisation syndrome (adult flatfoot with degenerative glenopathy). Pisani Giacomo Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons In cases of adult acquired flatfoot associated with peritalar destabilisation, special reference is made to the plantar calcaneo-navicular (spring) ligament's degenerative disease (degenerative glenopathy) and to the presence of the accessory navicular bone as a possible pathogenic cause. Peritalar destabilization syndrome is proposed for the articular (subtalar and talo-navicular joints) or tendinosis (tibialis posterior tendon) separately or in association with degenerative glenopathy of the coxa pedis. In degenerative glenopathy surgical reconstruction of the glenoid also makes use of a posterior tibial split to create a new tibial-navicular ligament. The concept of pronatory syndrome deemed as the root the pathological subtalar pronation, which is an entirely secondary factor in peritalar destabilisation, must be questioned. We must keep in mind that subtalar pronation and supination are respectively subsequent to opening and closing of the coxa pedis (talo-calcaneo-navicular joint) kinetic chain. 10.1016/j.fas.2009.10.011
Soft tissue procedures. Sitler David F,Bell S Josh Foot and ankle clinics Soft tissue procedures for PTT dysfunction and adult acquired flat foot improve function and preserve joint motion. These procedures can only be applied to patients who have correctable deformities. The durability of these procedures, without the addition of bone realignment procedures, has been questioned and needs to be investigated further. Reconstruction of the spring ligament complex corrects the flat foot in cadavers but has not been studied clinically. There is still much to be learned in this condition so we are able to provide optimal care for our patients. 10.1016/s1083-7515(03)00123-2
Would foot arch development in children characterize a body maturation process? A prospective longitudinal study. Biomedical journal BACKGROUND:Flatfoot (Pes Planus), often regarded as a physiological deviation in children, is of concern to parents because there is no test to predict the development of foot arch. This study aimed to use a new diagnostic flatfoot criterion to determine 1) how the footprint index changes during the development of foot arches, 2) what factors can predict a foot arch development, and 3) whether foot arch development could be a process of body growth. METHODS:572 children were enrolled in a prospective longitudinal study of anthropometrical parameters and physical fitness twice at age of 6.7 and 8.2 years. The bimodal frequency distribution of the Chippaux-Smirak index (CSI) of the footprint was used to define flatfoot as CSI &lt;0.58 and non-flatfoot as CSI &gt;0.61. Body measurements and physical fitness tests were compared between children with flatfeet who developed foot arches and children who did not. RESULTS:Of 263 children with flatfeet, the CSI significantly changed from 0.72 to 0.46 in 70 children who developed foot arches over 1.5 years and the others had minimal change in the index. Children with foot arch development had a lower initial CSI, improved boys' performance in one-leg balance, and less increase in girls' body height than children who remained flatfooted, whereas sex and weight were similar in both groups. CONCLUSION:This longitudinal study with the bimodal distribution of the CSI investigated how the development of foot arch advances in children around age 7. A significant and unique pattern in change of the CSI suggests involvement of a maturational stage in foot arch development. Along with the improved performance in one-leg balance, the unidirectional transition from flatfoot to non-flatfoot is associated with improvement in motor control of the ankle. TRIAL REGISTRATION:Chinese Clinical Trial Registry (ChiCTR-OCS-14004300). 10.1016/j.bj.2021.10.012
Effects of wearing shoes on the feet: Radiographic comparison of middle-aged partially shod Maasai women's feet and regularly shod Maasai and Korean women's feet. Choi Jun Young,Babu Heri,Joseph Francis Ngimwhichi,Stephanie Stephanie,Suh Jin Soo Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons BACKGROUND:Maasai tribe members walk long distances daily either barefoot or wearing traditional shoes made from recycled car tires, without any foot ailments. To figure out the characteristic of their feet, we designed a radiographic comparative study of middle-aged partially shod Maasai women's feet and regularly shod Maasai and Korean women's feet. METHODS:Weight bearing radiographs of bilateral foot and ankle joints from 20 healthy middle-aged bush-living partially shod (PS) Maasai women were obtained. Same number of radiographs from 20 urban-living regularly shod (RS) Maasai and 20 Korean women were obtained and compared. The hallux valgus angle, the first to second intermetatarsal angle, talonavicular coverage angle, talo-first metatarsal angle, Meary angle, naviculo-cuboidal overlap, and the medial cuneiform height were measured to establish the degree of pes plano-valgus and hallux valgus deformity. RESULTS:On comparing PS and RS Maasai groups radiographically, the talonavicular coverage angle, talo-first metatarsal angle, and naviculo-cuboidal overlap were significantly greater in the PS Maasai group, whereas hallux valgus angle, the first and second intermetatarsal angle, Meary angle, and the medial cuneiform height were greater in the RS Maasai and Korean group. CONCLUSIONS:Regularly wearing shoes would protect the feet from pes plano-valgus deformity, despite potentially contributing to hallux valgus deformity. 10.1016/j.fas.2017.03.012
Progression of planovalgus deformity in patients with cerebral palsy. Min Jae Jung,Kwon Soon-Sun,Sung Ki Hyuk,Lee Kyoung Min,Chung Chin Youb,Park Moon Seok BMC musculoskeletal disorders BACKGROUND:Analyzing radiographic changes of pes planovalgus(PV) deformity of cerebral palsy(CP) patients according to age and influencing factors. METHODS:CP patients with PV deformity younger than 18 years old who had undergone more than a year of follow-up with at least two standing foot radiographs were included. Anteroposterior and lateral talo-first metatarsal(talo-1stMT), talo-second metatarsal(talo-2ndMT), and hallux valgus(HV) angles were measured on the radiographs. The rate of progression was adjusted by multiple factors using the linear mixed model, with the Gross Motor Function Classification System(GMFCS) level as the fixed effect and age and each subject as random effects. RESULTS:Overall, 194 patients were enrolled in this study, and 1272 standing foot radiographs were evaluated. The AP talo-2MT angle progressed by 0.59° (p < 0.0001) and 0.64° (p = 0.0007) in GMFCS level II and III patients, respectively; however, there was no significant change in GMFCS level I patients (p = 0.3269). HV was significantly affected by age in all three GMFCS groups; it increased by 0.48° (p < 0.0001), 0.66° (p < 0.0001), and 1.19° (p < 0.0001) for levels I, II, and III, respectively. The lateral talo-1stMT angle showed improvements in GMFCS level I and II patients (0.43°, p < 0.0001, and 0.61°, p < 0.0001, respectively). In GMFCS level III patients, there was no significant improvement in the lateral talo-1MT angle (p = 0.0535). CONCLUSIONS:The GMFCS level was the single most important factor influencing the progression of radiographic indices in PV deformity in CP. The AP talo-1MT and talo-2ndMT angles progressed in patients with GMFCS levels II and III. Physicians should take this result into consideration when planning the timing of the surgery. LEVEL OF EVIDENCE:Prognostic Level IV. 10.1186/s12891-020-3149-0
Radiographic Study of Pes Planovarus. Aebi Janic,Horisberger Monika,Frigg Arno Foot & ankle international BACKGROUND:Depending on the direction of the subtalar joint, a foot deformity generally tends towards pronation (pes planovalgus) or supination (pes cavovarus). However, the combination of hindfoot varus and flat midfoot/forefoot (pes planovarus) is an exception to this rule. Pes planovarus has so far only been referred to in connection with Müller-Weiss disease and congenital disease. We diagnosed pes planovarus in otherwise healthy patients without these diseases. METHODS:Forty patients with 54 symptomatic feet who were treated between August 2012 and July 2016 were included (mean age, 44.1 ± 15.7 years; 15 male/25 female). They were selected from 1064 consecutive cases (3.8%). Inclusion criteria were hindfoot varus and flat midfoot/forefoot. Their symptoms, radiographs, and therapies within the first 3 months were retrospectively analyzed. The position in the hindfoot alignment view (HAV), talometatarsal-1 angle lateral (TMT1lat) and dorsoplantar (TMT1dp), talocalcaneal angle lateral (TCAlat) and dorsoplantar (TCAdp), and calcaneal pitch angle (CPA) were measured on a DICOM/PACS system. RESULTS:The mean radiological results (standard values from the literature in brackets) were as follows: the hindfoot was significantly in varus in the HAV (-6.9 ± 3.6 mm [-1.6 ± 7.2 mm]; P < .001), the TMT1lat was significantly flatter (-6.7 ± 5.8 degrees [8.4 ± 5.9 degrees]; P < .001), the TMT1dp was significantly less in abduction (1.5 ± 7.9 degrees [7.7 ± 8.2 degrees]; P = .005), the TCAdp showed no difference (25.9 ± 7.9 degrees [24.1 ± 5.7 degrees]; P = .118), the TCAlat was significantly larger (47.5 ± 6.1 degrees [43.4 ± 7.1 degrees]; P < .001), and the CPA was significantly flatter (17.6 ± 3.9 degrees [24.5 ± 3.0 degrees]; P < .001). The most frequent symptoms were stress-induced foot pain (n = 33), hallux valgus (n = 20), chronic ankle instability (n = 17), metatarsalgia (n = 15), chronic midfoot pain (n = 13), heel pain (n = 12), and lesser toe deformities (n = 8). Thirty-one feet were treated conservatively and 23 operatively. CONCLUSION:This study showed the existence of pes planovarus without Müller-Weiss disease or congenital disease. This unusual foot form leads to difficulties if standard treatment strategies are applied, which raises the issue of the correct treatment for such patients. LEVEL OF EVIDENCE:Level IV, retrospective case series. 10.1177/1071100717690440
Magnetic resonance imaging in adolescent painful flexible flatfoot. Wong Margaret W N,Griffith James F Foot & ankle international BACKGROUND:The cause of navicular tuberosity pain in adolescents with flexible flatfeet is not well understood. We hypothesized that some of the navicular tuberosity pain may be related to insertional enthesopathy of the posterior tibial tendon at the navicular. Magnetic resonance imaging was performed to look for abnormal signal changes in a series of patients. MATERIAL AND METHOD:Consecutive adolescent patients presenting with flexible flatfeet and navicular tuberosity pain were prospectively recruited. A detailed foot examination and body fat analysis was performed. Standing radiographs and Tekscan pedobarograph of both feet were obtained. Magnetic resonance examinations were performed on a 1.5-T whole-body magnetic resonance imaging system utilizing a standard extremity coil. RESULTS:MRI abnormality was detected in 15 of the 36 feet in 18 adolescents examined. Abnormalities detected included thickening of the posterior tibial tendon insertion, marrow edema in the accessory navicular, marrow edema in the navicular tuberosity, and contrast enhancement at the posterior tibial tendon insertion site. Patients with MRI abnormalities were significantly taller, had a lower body mass index and a lower body fat percentage than those without MRI abnormality. Forward stepwise logistic regression analysis identified low body fat percentage and presence of an accessory navicular as independent predictors for abnormality on MRI. CONCLUSION:MRI abnormality was frequently detected in adolescents with painful flexible flatfeet. The MRI signal changes indicated an enthesopathy like process occurring at the posterior tibial tendon insertion to the navicular which could explain the origin of pain in flexible flatfeet patients without an accessory navicular. Early identification and appropriate treatment to prevent progression may be helpful. 10.3113/FAI.2009.0303
Congenital paralytic vertical talus. An anatomical study. Specht E E The Journal of bone and joint surgery. American volume Dissections of the feet of a three-month-old infant with paralytic congenital vertical talus secondary to lumbar myelomeningocele were compared with a dissection of a normal foot. The major differences appeared to be absence of the plantar intrinsic muscles and dorsal dislocation of the talonavicular joint. It is postulated that the pathological process begins as a failure of the intrinsic muscles to oppose the unbalanced, active dorsiflexion forces of the anterior crural muscles. This imbalance then allows disruption of the talonavicular joint, mechanically the least stable joint in the mid-part of the foot. All dorsiflexion forces acting on the ankle then become ineffective and plantar flexion forces serve only to pull the calcaneus and talus into equinus, causing a "vertical" talus. Treatment must be directed at reducing the talonavicular dislocation, correcting the equinus deformity of the hind part of the foot, and substituting for the undeveloped plantar intrinsic muscles.
Isolated spring ligament failure as a cause of adult-acquired flatfoot deformity. Orr Justin D,Nunley James A Foot & ankle international BACKGROUND:Adult-acquired flatfoot deformity is usually secondary to failure of the tibialis posterior tendon, with secondary injury to the surrounding osseous-ligamentous complex. Rarely, patients may present with a normal tibialis posterior tendon and an isolated injury of the plantar calcaneonavicular, or spring, ligament. The current study describes the clinical presentation and operative management of 6 patients with isolated spring ligament ruptures who presented with symptomatic flexible flatfoot deformities. METHODS:Six consecutive patients with unilateral flatfoot deformities secondary to spring ligament failure were operatively treated at one institution between 2003 and 2010. All patients presented with symptomatic flatfoot deformities recalcitrant to conservative management. No patients had previous flatfoot reconstructive surgery, but all had undergone some combination of orthotic use, immobilization, or activity modifications prior to operative treatment. In each case, intraoperative findings demonstrated a tear of the spring ligament complex with a normal tibialis posterior tendon. To address the deformities, spring ligament repairs and adjunctive flatfoot reconstructions were performed. A retrospective chart study was performed to document patient presentation, demographics, and outcomes. RESULTS:Average patient age was 42 years. All 6 patients were female. All patients presented with medial foot pain for a mean of 27 months prior to presentation. Spring ligament abnormality was demonstrated in all 5 patients who received preoperative magnetic resonance imaging. Intraoperatively, all 6 patients demonstrated spring ligament tears and no significant tibialis posterior tendon abnormality. All 6 patients underwent spring ligament repairs with or without adjunctive flatfoot reconstructions. At mean follow-up of 13 months, all but 1 patient were pain-free without orthotics, and all patients were without residual deformity. There was a single patient with delayed bone graft healing and no other minor or major complications in this series. CONCLUSIONS:Adult-acquired flatfoot deformity is usually secondary to tibialis posterior tendon failure but in rare cases may be secondary to isolated spring ligament injury without tibialis posterior tendon abnormality. This unique clinical entity should be considered in patients who present with flatfoot deformities. In this study, although preoperative magnetic resonance imaging was not required, it identified a suspected spring ligament tear in all cases in which it was used. Thorough intraoperative exploration can identify an injury to the spring ligament and a normal tibialis posterior tendon. Failure to recognize an isolated spring ligament injury as the primary cause of a flatfoot deformity could lead to inappropriate operative management. LEVEL OF EVIDENCE:Level IV, retrospective study. 10.1177/1071100713483099
Relevant factors influencing flatfoot in preschool-aged children. Chen Kun-Chung,Yeh Chih-Jung,Tung Li-Chen,Yang Jeng-Feng,Yang Shun-Fa,Wang Chun-Hou European journal of pediatrics The aim of this study was to discuss the influence of age, gender, obesity status, joint laxity, and the W-sitting habit on flatfoot in preschool-aged children. A total of 1,598 children (833 boys and 765 girls) between 3 and 6 years of age from kindergartens in the central area of Taiwan were studied. The children were divided into a normal group (n = 733), a unilateral flatfoot group (n = 266), and a bilateral flatfoot group (n = 599), and a multinomial logistic regression model was used to analyze the data. The prevalence of flatfoot decreased significantly with increasing age: 54.5% of 3-year-old but only 21% for 6-year-old children had bilateral flatfoot. In the bilateral flatfoot group, the risk decreased with increased age, increased with increasing weight beyond the normal range, and was higher for boys than girls. Age and obesity status were not significantly influential in the unilateral flatfoot group. Children with higher joint laxity and a habit of W-sitting also experienced higher risk in both flatfoot groups. In conclusion, this study demonstrates a significant association of age, gender, obesity status, joint laxity, and the W-sitting habit with the bilateral flatfoot in preschool-aged children. Children with unilateral flatfoot differ from those with normal feet and bilateral flatfoot. It is suggested that the unilateral flatfoot deserves special attention in future studies. 10.1007/s00431-010-1380-7
Tendon disorders of the foot and ankle, part 3: the posterior tibial tendon. Gluck George S,Heckman Daniel S,Parekh Selene G The American journal of sports medicine This article provides a review of posterior tibial tendon pathology and the authors' preferred management. The tibialis posterior musculotendinous unit is the most powerful inverter of the foot and an important dynamic stabilizer of the arch. In the stance phase of the gait cycle, it serves as an initiator of both ankle plantar flexion and subtalar inversion. This creates a rigid midfoot by stabilizing the transverse tarsal joint, and allows for increased power generation by the gastrocsoleus complex through toe-off. Injuries to the posterior tibialis tendon include traumatic laceration and dislocation, as well as tenosynovitis and tendinopathy, which can lead to attenuation and rupture. If these injuries are not addressed, significant clinical deformity and disability can result. 10.1177/0363546509359492
Gait Analysis of Symptomatic Flatfoot in Children: An Observational Study. Kim Ha Yong,Shin Hyuck Soo,Ko Jun Hyuck,Cha Yong Han,Ahn Jae Hoon,Hwang Jae Yeon Clinics in orthopedic surgery BACKGROUND:Flatfoot deformity is a lever arm disease that incurs kinetic inefficiency during gait. The purpose of this study was to measure the degree of kinetic inefficiency by comparing the gait analysis data of a flatfoot group with a normal control group. METHODS:The patient group consisted of 26 children (21 males and 5 females) with symptomatic flatfoot. They were examined with gait analysis between May 2005 and February 2014. Exclusion criteria were patients with secondary flatfoot caused by neuromuscular disorders, tarsal coalition, vertical talus, or others. Patients' mean age was 9.5 years (range, 7 to 13 years). The gait analysis data of the study group and the normal control group were compared. RESULTS:The mean vertical ground reaction force (GRF) in the push-off phase was 0.99 for the patient group and 1.15 for the control group ( < 0.05). The mean ankle moment in the sagittal plane during the push-off phase was 0.89 for the patient group and 1.27 for the control group ( < 0.05). The mean ankle power in the sagittal plane during the push-off phase was 1.38 for the patient group and 2.52 for the control group ( < 0.05). The aforementioned results show that patients with pes planovalgus had a reduction of moment, power, and GRF in the push-off phase during gait. CONCLUSIONS:Symptomatic flatfeet had a moment inefficiency of 30% and power inefficiency of 45% during gait compared to feet with preserved medial longitudinal arches. 10.4055/cios.2017.9.3.363
Isolated spring ligament rupture causing acute flatfoot deformity: case report. Weerts Bas,Warmerdam Piet E,Faber Frank W M Foot & ankle international 10.3113/FAI.2012.0148
Biomechanical analysis of the calcaneocuboid joint pressure after sequential lengthening of the lateral column. Xia Jiang,Zhang Peng,Yang Yun-Feng,Zhou Jia-Qian,Li Qian-Ming,Yu Guang-Rong Foot & ankle international BACKGROUND:Lengthening of the lateral column by means of the Evans osteotomy is commonly used for reconstruction of adult and pediatric flatfoot. However, some reports have shown that the Evans osteotomy is linked with increased calcaneocuboid joint pressures and an increased risk of arthritis in the joint. The purpose of this study was to measure the pressure across the calcaneocuboid joint and demonstrate the changing trends of the pressure within the calcaneocuboid joint after sequential lengthening of the lateral column. METHODS:Six cadaver specimens were physiologically loaded and the peak pressure of the calcaneocuboid joint was measured under the following conditions: (1) normal foot, (2) flatfoot, and (3) sequential lengthening of the lateral column by means of the Evans procedure (from 4 mm to 12 mm, in 2 mm increments). RESULTS:Peak pressures across the joint increased significantly from baseline in the flatfoot (P < .05). In the corrected foot, with the increment of the graft, the peak pressure decreased initially and then increased. The pressure reached its minimum value (11.04 ± 1.15 kg/cm(2)) with 8 mm lengthening of the lateral column. The differences were significant compared to the flatfoot (P < .05) and corrected foot with the other sizes of grafts (P < .05), but differences were not significant compared to the intact foot (P = .143). CONCLUSIONS:Lateral column lengthening within a certain extent will decrease the pressure in calcaneocuboid joint with a flatfoot deformity. CLINICAL RELEVANCE:Performing the procedure with an 8 mm lengthening may reduce the risk of the secondary calcaneocuboid osteoarthritis. 10.1177/1071100712464211
Lateral column length in adult flatfoot deformity. Kang Steve,Charlton Timothy P,Thordarson David B Foot & ankle international INTRODUCTION:In adult acquired flatfoot deformity, it is unclear whether the lateral column length shortens with progression of the deformity, whether it is short to begin with, or whether it is short at all. To our knowledge, no previous study has examined the lateral column length of patients with adult acquired flatfoot deformity compared to a control population. The purpose of our study was to compare the lateral column length in patients with and without adult acquired flatfoot deformity to see if there was a significant difference. METHODS:The study was a retrospective radiographic review of 2 foot and ankle fellowship-trained orthopaedic surgeons' patients with adult flatfoot deformity. Our study population consisted of 75 patients, 85 feet (28 male, 57 female) with adult flatfoot deformity with a mean age of 64 (range, 23-93). Our control population consisted of 57 patients and 70 feet (23 male, 47 female) without flatfoot deformity with a mean age of 61 (range, 40-86 years). Weightbearing anteroposterior (AP) and lateral foot radiographs were analyzed for each patient, and the following measurements were made: medial and lateral column lengths, talonavicular uncoverage angle, talus-first metatarsal angle, calcaneal pitch angle, and medial and lateral column heights. An unpaired t test was used to analyze the measurements between the groups. Ten patients' radiographs were remeasured, and correlation coefficients were obtained to assess the reliability of the measuring techniques. RESULTS:For the flatfoot group, the mean medial and lateral column lengths on the AP radiograph were 108.6 mm and 95.8 mm, respectively; the mean talo-navicular uncoverage angle was 26.2 degrees; and the mean talus-first metatarsal angle was 20.0 degrees. In the control group, the mean medial and lateral column lengths on the AP radiograph were 108.8 mm and 96.5 mm, respectively; the mean talo-navicular uncoverage angle was 8.2 degrees; and the mean talus-first metatarsal angle was 7.7 degrees. On the lateral radiograph in the flatfoot group, the mean medial and lateral column lengths were 167.2 mm and 166.6 mm, respectively; the mean medial and lateral column heights were 16.0 mm and 14.7 mm, respectively; the mean calcaneal pitch angle was 15.6 degrees; and the talus-first metatarsal angle was 10.3 degrees and for the control group, the mean medial and lateral column lengths were 165.3 mm and 163.5 mm, respectively; the mean medial and lateral column heights were 22.8 mm and 13.1 mm, respectively; the mean calcaneal pitch angle was 22.4 degrees; and the talus-first metatarsal angle was -3.6 degrees. None of the differences in measurements for medial and lateral column lengths between the flatfoot and control groups achieved statistical significance. However, statistically significant differences between the 2 groups were observed in the measurements for medial and lateral column heights, talo-navicular uncoverage angle, calcaneal pitch angle, and talus-first metatarsal angle. CONCLUSION:There is no difference in lateral column lengths between patients with and without adult flatfoot deformity. The perceived shortened lateral column is likely due to forefoot abduction and hindfoot valgus deformities that are associated with adult flatfoot deformity. LEVEL OF EVIDENCE:Level III, comparative series. 10.1177/1071100712465738
The effect of backpack load on intersegmental motions of the foot and plantar pressure in individuals with mild flatfoot. Journal of foot and ankle research BACKGROUND:The feet play an essential role in shock absorption, and foot posture is closely related to gait. The compensatory mechanism under heavy-load conditions in individuals with mild flatfoot is poorly understood. In the authors' country, individuals with mild flatfoot are drafted as active-duty soldiers and participate in military rucking wearing heavy backpacks. This study investigated the effect of backpack load on gait and foot plantar pressure and possible differences in participants with mild flatfoot. The average weight of the backpack during military rucking (approximately 20 kg), was simulated in this study. METHODS:This study prospectively enrolled 30 healthy young males, divided into a control group (CON, n = 15) and a mild low-arched group (MLA, n = 15), based on the presence of flatfoot. Segmental foot kinematics were evaluated using a three-dimensional multi-segment foot model, and gait data of the temporal and spatial parameters were obtained. The dynamic plantar pressure was simultaneously measured using a pedobarography platform with gait trials. The protocol was repeated with all participants wearing 20 kg backpacks. Comparisons between the baseline and loaded states, as well as comparison between groups, were conducted. RESULTS:Although the cadence, gait speed, and stride length decreased in the loaded condition, step time and proportion of the stance phase increased in both groups. Although the MLA group showed more supinated and abducted positions of the forefoot and more pronated positions of the hindfoot than the CON group, the change in intersegmental foot and ankle motion in each group after backpack loading was minimal. However, the former showed a larger step width and a greater increase in contact area in the midfoot region, while the latter demonstrated a greater increase in peak pressure. CONCLUSIONS:Individuals with mild flatfoot demonstrated significantly different gait curve patterns (waveforms) compared to the controls. In the loaded condition, the CON and MLA groups may have adopted different strategies to maintain balance during gait. We suggest that although individuals with asymptomatic mild flatfoot are drafted as active-duty soldiers, they should be thoroughly investigated under loaded conditions, and orthoses may be helpful. 10.1186/s13047-022-00579-8
Hindfoot alignment valgus moment arm increases in adult flatfoot with Achilles tendon contracture. Arangio George,Rogman Alberic,Reed James F Foot & ankle international BACKGROUND:Adult acquired flatfoot is often associated with Achilles tendon contracture and may be associated with isolated spring ligament insufficiency without Achilles tendon contracture. We have studied the hypothesis that standing valgus hindfoot alignment moment arm is increased in adult acquired flatfoot with Achilles tendon contracture when compared to adult acquired flatfoot without Achilles tendon contracture. MATERIALS AND METHODS:The standing hindfoot alignment, standing lateral tibial-calcaneal angle, lateral talo-first metatarsal angle, lateral medial cuneiform arch height, and anteroposterior talonavicular coverage angle were measured in 22 patients with a clinical diagnosis of adult acquired flatfoot with one foot with clinical Achilles tendon contracture and one without that diagnosis. We compared the adult acquired flatfoot group to a control group of 15 patients with no foot or ankle deformities or previous foot or ankle surgeries. RESULTS:In patients with flatfoot and Achilles tendon contracture, there was a significantly increased valgus hindfoot alignment, talo-first metatarsal angle, talonavicular coverage angle, tibiocalcaneal angle and a decreased arch height when compared to the control group. In all flatfeet, we found an increased tibiocalcaneal angle. In both flatfoot groups, an increasing tibiocalcaneal angle and an increasing talo-first metatarsal angle was correlated to a decreasing arch height. In adult acquired flatfoot without Achilles tendon contracture diagnosed by clinical exam, an increasing talonavicular coverage angle was correlated to an increasing talo-first metatarsal angle and a decreasing arch height. CONCLUSION:Adults with flatfoot and Achilles tendon contracture have a significantly increased standing hindfoot valgus alignment moment arm and other associated deformities. 10.3113/FAI.2009.1078
Adult-acquired flatfoot deformity. Deland Jonathan T The Journal of the American Academy of Orthopaedic Surgeons Originally known as posterior tibial tendon dysfunction or insufficiency, adult-acquired flatfoot deformity encompasses a wide range of deformities. These deformities vary in location, severity, and rate of progression. Establishing a diagnosis as early as possible is one of the most important factors in treatment. Prompt early, aggressive nonsurgical management is important. A patient in whom such treatment fails should strongly consider surgical correction to avoid worsening of the deformity. In all four stages of deformity, the goal of surgery is to achieve proper alignment and maintain as much flexibility as possible in the foot and ankle complex. However, controversy remains as to how to manage flexible deformities, especially those that are severe. 10.5435/00124635-200807000-00005
Midterm assessment of subtalar arthroereisis for correction of flexible flatfeet in children. Bernasconi Alessio,Iervolino Cecilia,D'Alterio Rosa,Lintz François,Patel Shelain,Sadile Francesco Orthopaedics & traumatology, surgery & research : OTSR BACKGROUND:The role of subtalar arthroereisis (STA) for treating flexible flatfoot (FFF) in children is controversial. We hypothesized that (1) STA provided significant radiographic correction of low longitudinal arch and forefoot abduction in paediatric FFF and that (2) mid-term clinical outcomes were satisfactory and comparable to a normal population. METHODS:A retrospective comparative study was performed of paediatric patients with symptomatic FFF who underwent STA between 2012 and 2015. Multiple measurements on preoperative and latest follow-up radiographs were recorded by two observers and compared to assess for correction of the FFF. Intra- and inter-observer reliability was also assessed. Ankle and hindfoot range of motion (ROM), AOFAS hindfoot score and VAS-FA score were compared with controls without foot symptoms or deformity. From 70 consecutive feet, 62 (31 patients) treated at 10.5 years of age were identified and compared to 48 controls (24 patients). Mean follow-up was 62 months. RESULTS:Intra- and inter-observer reliability was excellent for all angles (range, 0.81-0.97). Radiographic measurements demonstrated significant improvement after surgery (p<0.001) but significance was not reached in talonavicular coverage angle (p=0.49) and calcaneo-fifth metatarsal angle (p=0.53) on dorsoplantar view. At latest follow-up, patients had less hindfoot inversion than controls (15.1̊ vs. 19.3̊, p=0.03), lower AOFAS scores (94.1 vs. 99.6 points, p=0.01), due to pain (p=0.01) and alignment (p=0.006) subscores. Using the VAS-FA score, patients were found to demonstrate higher pain at rest (prange, 0.02-0.03) and during activity (p=0.009), and felt limited when standing on one leg (p range, 0.01-0.03) and running (p=0.04). No loss of correction was found after removal of the implant. CONCLUSION:This study showed that STA corrected the low longitudinal arch in symptomatic paediatric FFF, but did not correct forefoot abduction in relation to the hindfoot. Mid-term assessment revealed STA provided satisfactory ankle and hindfoot ROM, pain and function levels, but limitations are witnessed compared to unaffected individuals. This aspect should be considered when counselling patients and their parents or caregivers to allow for realistic expectations. LEVEL OF EVIDENCE:III, retrospective comparative study. 10.1016/j.otsr.2019.10.012
Validity and diagnostic accuracy of foot posture Index-6 using radiographic findings as the gold standard to determine paediatric flexible flatfoot between ages of 6-18 years: A cross-sectional study. Hegazy Fatma A,Aboelnasr Emad A,Salem Yasser,Zaghloul Ashraf A Musculoskeletal science & practice BACKGROUND:Diagnosis of flexible flatfoot is usually based upon radiographic or clinical measures. Radiographic measures pose a potential risk of radiation exposure especially in Paediatric population. Clinicians need a valid, accurate, easily used, noninvasive and cost effective measure to evaluate static foot posture clinically. Although, foot posture index-6 (FPI-6) are commonly used in clinical practice, its validity and diagnostic accuracy in evaluation of paediatric flexible flatfoot have not been fully proven yet. OBJECTIVES:To investigate validity and diagnostic accuracy of FPI-6 to determine Paediatric flexible flatfoot between ages of 6-18 years using radiographic findings as the gold standard measure. STUDY DESIGN:Cross-sectional study. METHODS:A cross-sectional study conducted on 612 participants (1224 feet) with flexible flatfoot aged 6-18 years (mean age ± standard deviation of 12.36 ± 3.39 years). The results of FPI-6 were compared to the gold standard radiographic measures and displayed on the receiver operating characteristic curve. Intra-rater reliability, sensitivity, specificity, predictive values and likelihood ratios were calculated. Posttest probability was calculated from Fagan nomogram. RESULTS:FPI-6 demonstrate high intra-rater reliability (ICC = 0.96) with p value < 0.001. FPI-6 showed a sensitivity of 83.7%, a specificity of 80.4, a positive predictive value of 64.7, a negative predictive value of 92, a positive likelihood ratio of 4.62 and a negative likelihood ratio of 0.20. FPI-6 shows moderate diagnostic accuracy [AUC = 0.82; 95%CI (0.78-0.85)]. CONCLUSION:FPI-6 is valid with moderate diagnostic accuracy to determine paediatric flexible flatfoot between ages of 6-18 years. 10.1016/j.msksp.2020.102107
Effects of lower extremity rotation on prognosis of flexible flatfoot in children. Akcali O,Tiner M,Ozaksoy D Foot & ankle international The aim of this study is to search the effects of tibial torsion on flexible flatfoot. For this purpose, 20 children with flexible flatfoot and external tibial torsion were determined as a study group. The control group which consisted of 10 children with flexible flatfoot without rotational problems was included in the study. Plantar flexion angle of talus, talo-1. metatarsal angle and dorsoplantar talocalcaneal angle were measured on standing foot radiographs. Tibial torsion was measured by computed tomography. Plantar flexion angle of talus and dorsoplantar talocalcaneal angle were found significantly lower in the study group (p<0.005 and p<0.005 respectively), although talo-1. metatarsal angle was not significantly different between the groups (p=.2917). Naviculocuneiform sag was prominent in all cases of study group. In conclusion, abnormal external tibial torsion may affect the foot deformity and this can change the benign nature of the flexible flatfoot. 10.1177/107110070002100910
Evaluation and Management of Adolescents With a Stiff Flatfoot. The Journal of the American Academy of Orthopaedic Surgeons While flatfeet are normal in children, persistence into adolescence with associated pain or asymmetry warrants additional evaluation. Rigidity of a flatfoot deformity, whether a clinical report or evident on examination, should raise suspicion for pathology. The differential diagnosis includes tarsal coalition, neurogenic planovalgus, and peroneal spasticity. History must include pointed inquiry into birth and neurologic histories to probe for a source of central spasticity. Examination must include standing assessment of hindfoot and midfoot alignment. Hindfoot rigidity may be assessed by the double limb heel rise test and manual examination. Radiographs should include standing ankle (anterior-posterior and mortise) and whole foot (anterior-posterior, external rotation oblique, and lateral) images. Magnetic resonance imaging is more sensitive for identifying coalitions and better characterizes adjacent cartilage, subchondral edema, and tendon pathology, yet CT better characterizes the anatomy of a bony coalition. Conservative treatments are pathology-dependent and play a more prominent role in neurogenic or peroneal spastic flatfoot. Surgical management of coalitions is centered on coalition resection coupled with arthrodesis in the case of a talocalcaneal coalition with a dysplastic subtalar joint; concomitant planovalgus reconstruction is considered on a case-by-case basis. 10.5435/JAAOS-D-21-00448
Radiographic Assessment of Foot Alignment in Juvenile Hallux Valgus and Its Relationship to Flatfoot. Foot & ankle international BACKGROUND:The relationship between juvenile hallux valgus (JHV) and flatfoot has not been clearly established. The aim of this study was to assess radiographic measurements in feet with JHV compared with matched controls and to investigate whether the foot alignment of JHV is related to flatfoot. METHODS:We retrospectively reviewed 163 patients with JHV as defined as hallux valgus angle greater than 20 degrees and intermetatarsal greater than angle than 10 degrees. Patients with open physes of the feet and who had weight-bearing radiographs of the feet were included. Another 55 normal participants served as controls. Patients with JHV were divided into 2 subgroups: Group 1 included patients with asymptomatic JHV and group 2 consisted of those treated with correctional surgery for painful JHV. Twelve radiographic indices were analyzed, including calcaneal pitch angle, tibiocalcaneal angle, talocalcaneal angle, naviculocuboid overlap, talonavicular coverage angle, lateral talo-first metatarsal angle, anteroposterior talo-first metatarsal angle, metatarsus adductus angle, hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, and first metatarsal cuneiform angle. The groups were compared by age, gender, and the above radiographic parameters. RESULTS:There was no significant difference in hindfoot alignment of patients with JHV and controls. Naviculocuboid overlap ( <.001), lateral talo-first metatarsal angle ( = .002), and metatarsus adductus angle ( = .004) were significantly greater in patients with JHV than in controls, whereas the anteroposterior talo-first metatarsal angle ( = .026) was significantly less. Symptomatic and asymptomatic JHV patient subsets showed no significant radiologic differences. CONCLUSION:Radiographic profiles in patients with JHV were inconsistent with regard to features of flatfoot, and foot alignment was unrelated to the presence of symptoms or degree of deformity in JHV. LEVEL OF EVIDENCE:Level III, retrospective comparative series. 10.1177/1071100719850148
The arthroereisis procedure in adult flexible flatfoot grade IIA due to insufficiency of posterior tibial tendon. Ceccarini P,Rinonapoli G,Gambaracci G,Bisaccia M,Ceccarini A,Caraffa A Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons BACKGROUND:To report on the functional, biomechanical, and radiographic results of patients who had undergone arthroereisis plus tensioning of the posterior tibial tendon for flexible flatfoot. The hypothesis is that arthroereisis associated to a tensioning of the posterior tibial tendon give a good correction with great satisfaction in patients with flexible flatfoot in grade IIA. METHODS:We evaluated 29 patients (31 feet), mean age of 46.4 years, who had been surgically treated for adult flatfoot grade IIA according to Myerson. Mean follow-up was 34.15 months. For clinical evaluation, the AOFAS hindfoot and VAS-FA scores were used. RESULTS:Postoperative results showed significant increases in both AOFAS and VAS-FA scores: 54.2-81.9 and 61.5-83.2 points, respectively. For the X-ray parameters, we observed a significant variation in the talo-first metatarsal angle, from 13.8° in pre-op to 7.4° in post-op. In lateral view, Djian Annonier angle was improved from 146.6° to 134.1°. The Meary's angle, compared to an average of 8.8° in pre-operative stage improved to 4.3° in the post-operative stage. Postoperative satisfaction was excellent-good according to 23 patients (79.4%). Pain in the tarsal sinus was reported in 5 out of 31 feet (16.1%) for the first three months after surgery. CONCLUSIONS:Arthroereisis and tensioning of the posterior tibial tendon provided good functional outcomes for patients under 60 years of age having stage IIA flexible flatfoot without arthritic manifestations. 10.1016/j.fas.2017.04.003
Flatfoot diagnosis by a unique bimodal distribution of footprint index in children. Chang Chia-Hsieh,Chen Yu-Chen,Yang Wen-Tien,Ho Pei-Chi,Hwang Ai-Wen,Chen Chien-Hung,Chang Jia-Hao,Chang Liang-Wey PloS one BACKGROUND:More than 1000 scientific papers have been devoted to flatfoot issue. However, a bimodal distribution of flatfoot indices in school-aged children has never been discovered. The purposes of this study were to establish a new classification of flatfoot by characteristic in frequency distribution of footprint index and to endue the classification with discrepancy in physical fitness. METHODS/PRINCIPAL FINDINGS:In a longitudinal survey of physical fitness and body structure, weight bearing footprints and 3 physical fitness related tests were measured in 1228 school-aged children. Frequency distribution of initial data was tested by Kolmogorov-Smirnov test for normality and a unique bimodal distribution of footprint index was identified. The frequency distribution of footprint index manifests two distinct modes, flatfoot and non-flatfoot, by deconvolution and bootstrapping procedures. A constant intersection value of 1.0 in Staheli's arch index and 0.6 in Chippaux-Smirak index could distinguish the two modes of children, and the value was constant in different age, sex, and weight status. The performance of the one leg balance was inferior in flatfoot girls (median, 4.0 seconds in flatfoot girls vs. 4.3 seconds in non-flatfoot girls, p = 0.04, 95% CI 0.404-0.484). DISCUSSION:The natural bimodality lends itself to a flatfoot classification. Bimodality suggests development of the child's foot arch would be a leap from one state to another, rather than a continuous growth as body height and weight. The underlying dynamics of the human foot arch and motor development will trigger research prospects. 10.1371/journal.pone.0115808
Spring ligament complex and flatfoot deformity: curse or blessing? Deland Johnathan T Foot & ankle international 10.3113/FAI.2012.0239
Flexible flatfoot and related factors in primary school children: a report of a screening study. El Ozlem,Akcali Omer,Kosay Can,Kaner Burcu,Arslan Yasemin,Sagol Ertan,Soylev Serdar,Iyidogan Dursun,Cinar Nuray,Peker Ozlen Rheumatology international The aim of this study was to analyze the longitudinal arch morphology and related factors in primary school children. Five hundred and seventy-nine primary school children were enrolled in the study. Generalized joint laxity, foot progression angle, frontal hindfoot alignment, and longitudinal arch height in dynamic position were evaluated. The footprints were recorded by Harris and Beath footprint mat and arch index of Staheli was calculated. The mean age was 9.23 +/- 1.66 years. Four hundred and fifty-six children (82.8%) were evaluated as normal and mild flexible flatfoot, and 95 children (17.2%) were evaluated as moderate and severe flexible flatfoot. The mean arch indices of the feet was 0.74 +/- 0.25. The percentage of flexible flatfoot in hypermobile and non-hypermobile children was found 27.6 and 13.4%, respectively. There was a statistically significant difference in dynamic arch evaluation between hypermobile and non-hypermobile children. There was a significant negative correlation between arch index and age, and a significant negative correlation between hypermobility score and age. Our study confirms that the flexible flatfoot and the hypermobility are developmental profiles. 10.1007/s00296-006-0128-1
Association between subtalar articular surface typing and flat foot deformity: which type is more likely to cause flat foot deformity. Zhang Lei,Peng Xiaoyao,He Siyuan,Zhou Xin,Yi Gang,Tang Xiaogao,Li Bingkun,Wang Guoyou,Zhao Wanxue,Yang Yuening BMC musculoskeletal disorders BACKGROUND:Previous studies have shown a wide range of anatomical classifications of the subtalar joint (STJ) in the population and this is related to the different force line structures of the foot. Different subtalar articular surface morphology may affect the occurrence and development of flat foot deformity, and there are fewer studies in this area. The main objective of our study was to determine the association of different subtalar articular surface with the occurrence and severity of flat foot deformity. METHODS:We analyzed the imaging data of 289 cases of STJ. The articular surface area, Gissane's angle and Bohler's angle of subtalar articular surface of different types were counted. The occurrence and severity of flat foot deformity in different subtalar articular surface were judged by measuring the Meary angle of foot. RESULTS:We classified 289 cases of subtalar articular surface into five types according to the morphology. According to Meary angle, the flat foot deformity of Type I and Type IV are significantly severer than Type II (P < 0.05). Type II (7.65 ± 1.38 cm) was significantly smaller than Type I (8.40 ± 1.79 cm) in the total joint facet area(P < 0.05). Type III (9.15 ± 1.92 cm) was smaller than Type I (8.40 ± 1.79 cm), II (7.65 ± 1.38 cm) and IV (7.81 ± 1.74 cm) (P < 0.05). Type II (28.81 ± 7.44) was significantly smaller than Type I (30.80 ± 4.61 degrees), and IV (32.25 ± 5.02 degrees) in the Bohler's angle (P < 0.05). Type II (128.49 ± 6.74 degrees) was smaller than Type I (131.58 ± 7.32 degrees), and IV (131.94 ± 5.80 degrees) in the Gissane's angle (P < 0.05). CONCLUSIONS:After being compared and analyzed the measurement of morphological parameters, joint facet area and fusion of subtalar articular surface were closely related to the severity of flat foot deformity and Type I and IV were more likely to develop severer flat foot deformity. LEVEL OF EVIDENCE:Level III, retrospective comparative study. 10.1186/s12891-021-04872-8
Comparative biomechanical effectiveness of over-the-counter devices for individuals with a flexible flatfoot secondary to forefoot varus. Hurd Wendy J,Kavros Steven J,Kaufman Kenton R Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine OBJECTIVES:Evaluate effects of a new off-the-shelf insert on frontal plane foot biomechanics and compare effectiveness of the new and an existing off-the-shelf insert and a motion-control shoe in neutralizing frontal plane foot biomechanics. DESIGN:Descriptive. SETTING:Biomechanics laboratory. PARTICIPANTS:Fifteen uninjured subjects with a flexible flatfoot secondary to forefoot varus. ASSESSMENT OF RISK FACTORS:Three-dimensional kinematic and kinetic data were collected as subjects walked and jogged at their self-selected speed while wearing a motion-control running shoe, the shoe with a new off-the-shelf insert, and the shoe with an existing off-the-shelf insert. MAIN OUTCOME MEASURES:Frontal plane kinematics and rearfoot kinetics were evaluated during stance. Statistical analysis was performed using a repeated measures analysis of variance and Student-Newman-Keuls post hoc tests (α ≤ 0.05). RESULTS:The new insert and motion-control shoe placed the forefoot in a less-everted position than the existing off-the-shelf insert during walking. There were no differences in forefoot kinematics during jogging, nor were there differences in rearfoot motion during walking or jogging. The rearfoot eversion moment was significantly lower with the new off-the-shelf insert compared with the motion-control shoe and the existing insert during walking and jogging. CONCLUSIONS:A new off-the-shelf device is available that promotes more neutral frontal plane biomechanics, thus providing a theoretical rationale for using this device for injury prevention and treatment. The comparative biomechanical effectiveness of a motion-control shoe and the orthotic inserts may assist health care professionals in selecting a device to correct the flatfoot structure. 10.1097/JSM.0b013e3181fb539f
Response to "Letter Regarding: Pes Planus Deformity and Its Association With Hallux Valgus Recurrence Following Scarf Osteotomy". Foot & ankle international 10.1177/1071100720975714
3D measurement techniques for the hindfoot alignment angle from weight-bearing CT in a clinical population. Scientific reports Cone-beam CT (CBCT) scans now enable accurate measurements on foot skeletal structures with the advantage of observing these in 3D and in weight-bearing. Among the most common skeletal deformities, the varus/valgus of the hindfoot is the most complex to be represented, and a number of measure proposals have been published. This study aims to analyze and to compare these measurements from CBCT scans in a real clinical population with large such deformity. Ten patients with severe acquired adult flatfoot and indication for surgery underwent CBCT scans (Carestream, USA) while standing on that leg, before and after surgical correction. Corresponding 3D shape of each bone of the distal shank and hindfoot were defined (Materialise, Belgium). Six different techniques from the literature were used to calculate the varus/valgus deformity, i.e. the inclination of the hindfoot in the frontal plane of the shank. Standard clinical measurements by goniometers were taken for comparison. According to these techniques, and starting from a careful 3D reconstruction of the relevant foot skeletal structures, a large spectrum of measurements was found to represent the same hindfoot alignment angle. Most of them were very different from the traditional clinical measures. The assessment of the pre-operative valgus deformity and of the corresponding post-operative correction varied considerably. CBCT finally allows 3D assessment of foot deformities in weight-bearing. Measurements from the different available techniques do not compare well, as they are based on very different approaches. It is recommended to be aware of the anatomical and functional concepts behind these techniques before clinical and surgical conclusions. 10.1038/s41598-022-21440-9
Change in flatfoot of preschool-aged children: a 1-year follow-up study. Chen Kun-Chung,Tung Li-Chen,Yeh Chih-Jung,Yang Jeng-Feng,Kuo Jing-Fu,Wang Chun-Hou European journal of pediatrics UNLABELLED:The main purpose of this study is to investigate the changes in the signs of flatfoot of preschool-aged children in a 1-year follow-up study. This study performed follow-up on a total of 580 preschool-aged children (boys, 297 children; girls, 283 children) with a median age of 54 (range 36-71 months), and the average follow-up period was 11.8 months. This study used the Chippaux-Smirak index (CSI) of footprint as the assessment tool, and CSI > 62.70 % was used as the standard for determining whether preschool-aged children suffered from flatfoot. The results showed that the signs of flatfoot of preschool-aged children improved with increasing age. At the 1-year follow-up, the average CSI was 5.1 % lower, and the proportion of children with flatfoot was 14 % lower. The follow-up on the change in the signs of flatfoot showed that 37.6 % of the children originally with flatfoot had improved to normal, verifying that flatfoot indeed improves with increasing age. However, the results also showed that 9.9 % of the children who originally had normal feet had developed flatfoot with increasing age, which deserves subsequent investigation. The results of the follow-up also showed that children who were relatively younger, male, obese, and experiencing excessive joint laxity were more likely to experience the signs of flatfoot. CONCLUSION:The 1-year follow-up found that some preschool-aged children with flatfoot may develop normal feet, while children with normal feet may begin to experience the signs. Relevant factors affecting flatfoot in preschool-aged children continue to require further clarification. 10.1007/s00431-012-1884-4
Correlation of Harris mats, physical exam, pictures, and radiographic measurements in adult flatfoot deformity. Coughlin Michael J,Kaz Ari Foot & ankle international INTRODUCTION:In many reports describing flatfoot deformities, the abnormality is described using observations from physical examination, radiographs, or foot imprints. Correlation of these measurements is often lacking, making determination of the magnitude of the deformity or its surgical correction difficult to quantify. MATERIAL AND METHODS:Weightbearing AP and lateral radiographs were obtained on 25 patients (39 feet) with a clinically apparent flatfoot deformity and an asymptomatic control group of 28 subjects (56 feet). Radiographs were examined for the lateral talometatarsal angle, the lateral talocalcaneal angle, calcaneal pitch, first metatarsocuneiform height, medial cuneiform -fifth metatarsal height, metatarsus primus elevatus, plantar gapping at the first metatarsocuneiform joint, the AP talonavicular coverage angle, and the metatarsus adductus angle. Harris mat imprints were obtained on each foot and measured for the magnitude of the flatfoot deformity. Physical examination included the subjective appearance to the examiner of the degree of pes planus (none, mild, moderate, severe), hindfoot valgus, and ankle range of motion. Photographs of the hindfoot were obtained in a standardized manner, and hindfoot valgus was measured from these photos and compared to the measured hindfoot valgus on the physical exam. RESULTS:Statistically significant differences between the two groups were found in the lateral talometatarsal angle, lateral talocalcaneal angle, calcaneal pitch, first metatarsocuneiform height, the AP talonavicular coverage angle, Harris mat imprint score, subjective pes planus score, hindfoot valgus measurement from both photographs and physical examination, ankle range of motion (all with a p value less than 0.01), and the metatarsus adductus angle (p = 0.019). No patient in the control group and 14 (36%) in the flatfoot group had evidence of plantar gapping at the first metatarsocuneiform joint. In the flatfoot group, statistically significant correlations were demonstrated between the Harris mat score and heel valgus as measured by photographic and physical examination, subjective pes planus grading by physical exam, the lateral talometatarsal angle, and the first metatarsocuneiform height. CONCLUSION:This study validates the use of the Harris mat imprint as an effective method of quantifying the magnitude of a flatfoot deformity. We also found a statistically significant decrease in ankle range of motion in the flatfoot group, indicating that tightness of the gastrocsoleus complex is part of the pathophysiology of flatfoot deformity. 10.3113/FAI.2009.0604
A comparison of foot kinematics in people with normal- and flat-arched feet using the Oxford Foot Model. Levinger Pazit,Murley George S,Barton Christian J,Cotchett Matthew P,McSweeney Simone R,Menz Hylton B Gait & posture Foot posture is thought to influence predisposition to overuse injuries of the lower limb. Although the mechanisms underlying this proposed relationship are unclear, it is thought that altered foot kinematics may play a role. Therefore, this study was designed to investigate differences in foot motion between people with normal- and flat-arched feet using the Oxford Foot Model (OFM). Foot posture in 19 participants was documented as normal-arched (n=10) or flat-arched (n=9) using a foot screening protocol incorporating measurements from weightbearing antero-posterior and lateral foot radiographs. Differences between the groups in triplanar motion of the tibia, rearfoot and forefoot during walking were evaluated using a three-dimensional motion analysis system incorporating a multi-segment foot model (OFM). Participants with flat-arched feet demonstrated greater peak forefoot plantar-flexion (-13.7° ± 5.6° vs -6.5° ± 3.7°; p=0.004), forefoot abduction (-12.9° ± 6.9° vs -1.8° ± 6.3°; p=0.002), and rearfoot internal rotation (10.6° ± 7.5° vs -0.2°± 9.9°; p=0.018) compared to those with normal-arched feet. Additionally, participants with flat-arched feet demonstrated decreased peak forefoot adduction (-7.0° ± 9.2° vs 5.6° ± 7.3°; p=0.004) and a trend towards increased rearfoot eversion (-5.8° ± 4.4° vs -2.5° ± 2.6°; p=0.06). These findings support the notion that flat-arched feet have altered motion associated with greater pronation during gait; factors that may increase the risk of overuse injury. 10.1016/j.gaitpost.2010.07.013
Effect of foot orthoses on 3-dimensional kinematics of flatfoot: a cadaveric study. Kitaoka Harold B,Luo Zong-Ping,Kura Hideji,An Kai-Nan Archives of physical medicine and rehabilitation OBJECTIVE:To test in cadaveric feet the hypothesis that prefabricated foot orthoses will improve arch alignment in flatfoot deformity. DESIGN:Experimental, paired comparisons. SETTING:Biomechanics laboratory. CADAVERS:Nine cadaveric lower-extremity specimens with no abnormalities. INTERVENTIONS:To evaluate the performance of 2 orthoses specimens were tested in 4 combinations: intact, flatfoot, flatfoot with shoe and orthosis 1, and flatfoot with shoe and orthosis 2. To simulate the midstance phase of gait, loads were applied to 5 tendons and an axial load equivalent to two thirds of the standing load was applied to the foot's plantar surface. MAIN OUTCOME MEASURES:Arch height and tarsal bone positions before and after a flatfoot deformity created by ligament sectioning; tarsal bone positions determined with a magnetic tracking system. RESULTS:After ligament sectioning, the average decrease in arch height with a shoe applied was 4.6+/-1.6mm (8%); with orthosis 1, mean arch height increased 0.7+/-0.6mm (P=.008); with orthosis 2, it increased 0.3+/-0.5mm (P=.05). With both orthoses, arch height after sectioning was significantly less than that of the normal arch. Compared with the flatfoot condition, metatarsal-talar alignment improved in plantar flexion and inversion with both orthoses but did not approximate normal with either orthosis. Calcaneal-tibial position did not improve with either orthosis and was markedly different from that in the intact foot with either orthosis. No difference was found between the 2 orthoses except for metatarsal-talar motion in external rotation (P=.014) and eversion (P=.026). CONCLUSIONS: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.
Validation of the Foot and Ankle Outcome Score in adult acquired flatfoot deformity. Mani Sriniwasan B,Brown Haydée C,Nair Pallavi,Chen Lan,Do Huong T,Lyman Stephen,Deland Jonathan T,Ellis Scott J Foot & ankle international INTRODUCTION:The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score has been under recent scrutiny. The Foot and Ankle Outcome Score (FAOS) is an alternative subjective survey, assessing outcomes in 5 subscales. It is validated for lateral ankle instability and hallux valgus patients. The aim of our study was to validate the FAOS for assessing outcomes in flexible adult acquired flatfoot deformity (AAFD). METHODS:Patients from the authors' institution diagnosed with flexible AAFD from 2006 to 2011 were eligible for the study. In all, 126 patients who completed the FAOS and the Short-Form 12 (SF-12) on the same visit were included in the construct validity component. Correlation was deemed moderate if the Spearman's correlation coefficient was .4 to .7. Content validity was assessed in 63 patients by a questionnaire that asked patients to rate the relevance of each FAOS question, with a score of 2 or greater considered acceptable. Reliability was measured using intraclass correlation coefficients (ICCs) in 41 patients who completed a second FAOS survey. In 49 patients, preoperative and postoperative FAOS scores were compared to determine responsiveness. RESULTS:All of the FAOS subscales demonstrated moderate correlation with 2 physical health related SF-12 domains. Mental health related domains showed poor correlation. Content validity was high for the Quality of Life (QoL; mean 2.26) and Sports/Recreation subscales (mean 2.12). All subscales exhibited very good test-retest reliability, with ICCs of .7 and above. Symptoms, QoL, pain, and daily activities (ADLs) were responsive to change in postoperative patients (P < .05). CONCLUSION:This study has validated the FAOS for AAFD with acceptable construct and content validity, reliability, and responsiveness. Given its previous validation for patients with ankle instability and hallux valgus, the additional findings in this study support its use as an alternative to less reliable outcome surveys. LEVEL OF EVIDENCE:Level II, prospective comparative study. 10.1177/1071100713483117
Assessment of Flatfoot Deformity Using Digitally Reconstructed Radiographs: Reliability and Comparison to Conventional Radiographs. Foot & ankle international BACKGROUND:Digitally reconstructed radiographs (DRRs) generated from weightbearing computed tomography (WBCT) may potentially substitute for weightbearing plain radiographs (XRs) but have not been clinically validated. This study aims to test the reliability of 6 radiographic parameters of progressive collapsing foot deformity (PCFD) as measured on DRR, to investigate whether DRR represents comparably to XR through the same measurements, and to compare agreement of DRR and XR measurements of a standardized arch height parameter with reference measurements made on WBCT. METHODS:DRR generated from preoperative WBCT of 71 patients (72 feet) treated surgically for PCFD were retrospectively compared with preoperative weight-bearing XR after exclusion criteria were applied. Six radiographic measurements were performed, including Meary angle, calcaneal pitch (CPA), medial cuneiform height (MCH), AP talar-first metatarsal angle (T-1MT), talonavicular coverage (TNCA), and talar incongruency (TIA). Arch height was measured on XR, DRR, and WBCT using a validated, standardized, navicular-based index. Intraclass correlation coefficients assessed DRR intraobserver and interobserver reliability. Paired samples tests tested differences between XR and DRR. Bland-Altman limits of agreement analysis compared DRR and XR agreement with WBCT measurements. RESULTS:Measurements were within standard PCFD ranges on XR and DRR. All measurements demonstrated excellent intrarater reliability and good to excellent interrater agreement, consistent with previous literature on XR. No differences were found for Meary, CPA, or TNCA. Minor differences were observed for MCH, T-1MT, and TIA. DRR measurements demonstrated greater agreement with WBCT than XR measurements. CONCLUSION:DRR from WBCT may be a promising substitute for XR in the clinical evaluation of PCFD. Radiographic measurements made on DRR demonstrated good to excellent reliability. Although small differences were found between XR and DRR for certain measurements, DRR more accurately represented medial arch anatomy compared to gold standard WBCT data than XR. If validated as a clinical substitute, DRR could eventually obviate XR where WBCT is available. LEVEL OF EVIDENCE:Level III, retrospective cohort study. 10.1177/10711007221089260
Preventive strategy of flatfoot deformity using fully automated procedure. Hu Che-Wei,Dabnichki Peter,Baca Arnold,Nguyen Canh Toan,Pang Toh Yen Medical engineering & physics A non-invasive, no radiation, out-of-hospital automated system is proposed to identify low arch integrated in the design and manufacturing of personalized orthoses using parametric modelling. The aim of the design process is to integrate assistive technology with assessment and prevent low arch progressing to a more serious case - flatfoot. In the automated procedure, we developed an assessment method including reliable thresholds of foot type classification and test protocol to reduce interferences due to preceding activities, an automation to translate scanned data into parametric design for orthotic customization, finite element model evaluating effectiveness of the personalized design, and a personalized comparative test to evaluate the long-term improvement of foot arch shape. Our low arch threshold established by subject-specific 3D models reduced the misclassification rate from 55%, as previously reported to 6.9%. Individuals who engaged in sedentary activity (i.e. sitting) had the greater change in arch height compared to active activity (i.e. standing and walking), which is more likely to affect the obtained measure. Therefore, a test protocol now states that participants are not allowed to sit over 100 min prior the measurement to reduce such interference. We have proposed and tested an automated algorithm to translate scanned data including seven foot's parameters into customised parametric design of the insert. The method decreases the required time of orthotic computer-aided design from over 3 h to less than 2 min. A finite element analysis procedure was additionally developed to assess the performance of geometries and material of designed orthotic based on the distribution of plantar pressure and internal stress. The personalized comparative assessment based on midfoot contact area was carried out periodically for follow-up and the orthotic could be re-designed if necessary. The proposed automated procedure develops a pre-screening system to distinguish low arch and provide preventatives before it becomes symptomatic. Furthermore, non-symptom flatfoot can be detected at early stages and referred to medics for further diagnosis or treatment. 10.1016/j.medengphy.2021.07.006
Trends in hospitalization for paediatric flatfoot: an Italian nationwide study from 2001 to 2016. BMC pediatrics BACKGROUND:Flatfoot is a common condition in young patients, but usually resolves by adolescence. This study aimed to estimate annual trend hospitalizations for flatfoot in Italian paediatric population from 2001 to 2016. METHODS:Data of this study were collected from the National Hospital Discharge Reports (SDO) reported at the Italian Ministry of Health regarding the years of this paper (2001-2016). The yearly number of hospital admission for flatfoot, the percentage of males and females, the average age, the average days of hospitalization, primary diagnoses and primary procedures in the whole Italian population were calculated using descriptive statistical analyses. RESULTS:109,300 hospitalizations for flatfoot of young patients were performed during this period. 59.3% of patients were male and 40.7% female of the 10-14 years-old age class. The average days of hospitalization stay were 1.73 ± 1.27 days. The data highlights that the burden of flatfoot surgery is growing and affecting the healthcare system. The mean rate of hospital admissions in Italy for flatfoot in the young population was 82.14 for 100,000 inhabitants of the same age class. CONCLUSIONS:The data highlights that the cases of flatfoot surgery increased from 2001 to 2016. The most common treatment was the "Internal Fixation Of Bone Without Fracture Reduction, Tarsals And Metatarsals followed by Subtalar Fusion and Arthroereisis. Further prospective studies on this topic may be conducted to improve the evidence of the results. 10.1186/s12887-022-03145-0
Talus morphology differs between flatfeet and controls, but its variety has no influence on extent of surgical deformity correction. Archives of orthopaedic and trauma surgery BACKGROUND:Progressive collapsing foot deformity (PCFD) is a complex 3-dimensional (3-D) deformity with varying degrees of hindfoot valgus, forefoot abduction, and midfoot varus. The first aim of this study was to perform a 3-D analysis of the talus morphology between symptomatic PCFD patients that underwent operative flatfoot correction and controls. The second aim was to investigate if there is an impact of individual talus morphology on the success of operative flatfoot correction. METHODS:We reviewed all patients that underwent lateral calcaneal lengthening for correction of PCFD between 2008 and 2018 at our clinic. Radiographic flatfoot parameters on preoperative and postoperative radiographs were assessed. Additionally, 3-D surface models of the tali were generated using computed tomography (CT) data. The talus morphology of 44 flatfeet was compared to 3-D models of 50 controls without foot or ankle pain of any kind. RESULTS:Groups were comparable regarding demographics. Talus morphology differed significantly between PCFD and controls in multiple aspects. There was a 2.6° increased plantar flexion (22.3° versus 26°; p = 0.02) and medial deviation (31.7° and 33.5°; p = 0.04) of the talar head in relation to the body in PCFD patients compared to controls. Moreover, PCFD were characterized by an increased valgus (difference of 4.6°; p = 0.01) alignment of the subtalar joint. Satisfactory correction was achieved in all cases, with an improvement of the talometatarsal-angle and the talonavicular uncoverage angle of 5.6° ± 9.7 (p = 0.02) and 9.9° ± 16.3 (p = 0.001), respectively. No statistically significant correlation was found between talus morphology and the correction achieved or loss of correction one year postoperatively. CONCLUSION:The different morphological features mentioned above might be contributing or risk factors for progression to PCFD. However, despite the variety of talar morphology, which is different compared to controls, the surgical outcome of calcaneal lengthening osteotomy was not affected. LEVEL OF EVIDENCE:III. 10.1007/s00402-021-03925-w
Assessment of the medial longitudinal arch in children and adolescents with obesity: footprints and radiographic study. Villarroya M Adoración,Esquivel J Manuel,Tomás Concepción,Moreno Luis A,Buenafé Ana,Bueno Gloria European journal of pediatrics The purpose of this study was to evaluate foot arch types of obese children and adolescents aged 9-16.5 years using both indirect and direct measures. Fifty-eight obese children/adolescents attending the paediatric endocrinology unit of the University Hospital "Lozano Blesa" in Zaragoza were selected as experimental subjects. Fifty-eight gender and age matched, normal-weight children/adolescents were selected as control subjects. To assess the medial longitudinal arch (MLA) height, which is used as a main reference for the diagnosis of flatfoot, footprints from both feet were collected (in both groups) and lateral weight-bearing radiographs of both feet were taken (of 49 of the 58 obese children). Footprint angle (FA) and the Chippaux-Smirak index (CSI) were calculated from the footprints. Talus-first metatarsal (TFMA) and calcaneal inclination angles (CIA) were obtained from lateral feet radiographs. In the normal-weight group, mean values of FA and CSI indicated a normal MLA. In the obese group, morphological flatfoot was identified. Comparison between both groups, by side and gender, showed a decrease of FA (p<0.001) and an increase of CSI (p<0.001) in obese subjects. Mean values of TFMA and CIA in the obese group indicated a lowering of the MLA. Obese children/adolescents between 9 and 16.5 years of age had significantly lower values of FA and higher CSI, related to a lower MLA. Radiographic parameters supported these findings and mean values were associated with a fall of this arch. 10.1007/s00431-008-0789-8
Subluxation of the talocalcaneal joint in adults who have symptomatic flatfoot. Ananthakrisnan D,Ching R,Tencer A,Hansen S T,Sangeorzan B J The Journal of bone and joint surgery. American volume BACKGROUND:When flatfoot is acquired during adulthood, the shape of the foot changes. In addition to a decreased arch, there may be valgus angulation of the hindfoot or abduction of the forefoot, or both. However, there is little objective information to provide a better understanding of the anatomical or morphological changes that occur in acquired adult flatfoot. We wondered if such an understanding of the three-dimensional anatomy might shed light on the pathway by which these changes occur. We designed this study to measure the three-dimensional position of the talocalcaneal joint in patients who have painful flatfoot. METHODS:Computed tomography scans of the feet of eight patients who had symptomatic flatfoot were used to construct a model of the talocalcaneal articulation. The scans were performed on a custom loading frame developed to simulate weight-bearing with the foot in a neutral position while a seventy-five-newton axial compressive load was applied. The digital data from the scans were used to make three-dimensional computer models of the articular surfaces of the talus and calcaneus of each foot. These models then were used to calculate the percentage of the articular surface that was in contact and, conversely, the percentage that was subluxated. Two surfaces were modeled for each bone; the posterior facet formed one surface, and the anterior and middle facets were combined to form the second surface. The data were compared, with use of Mann-Whitney nonparametric U analysis, with those derived from scans of the feet of four patients without a deformity of the hindfoot who served as controls. RESULTS:A mean (and standard deviation) of 68+/-9 percent of the posterior facet of the calcaneus was in contact with the talus in the patients who had flatfoot compared with 92+/-2 percent in the controls, and a mean of 51+/-23 percent of the anterior and middle facets of the calcaneus was in contact with the talus in the patients who had flatfoot compared with 95+/-6 percent in the controls. These differences were significant (p = 0.0066 for both). CONCLUSIONS:Marked subluxation of the talocalcaneal joint occurs in some patients who have symptomatic planoabductovalgus deformity. 10.2106/00004623-199908000-00010
Does the way of weight-bearing matter? Single-leg and both-leg standing radiographic and pedobarographic differences in pediatric flatfoot. Gait & posture BACKGROUND:An exact definition is lacking for the term "weight-bearing" or different standing modalities when implementing foot radiographs for children and adults; moreover, only few studies have investigated the relationship between radiographic and pedobarographic measurements. RESEARCH QUESTION:We hypothesized that the method of weight-bearing in single-leg and both-leg standing positions could influence the measurement results in radiographs and the distribution of foot pressure. METHODS:This prospective study evaluated 33 children (66 feet) with flexible flatfoot deformities scheduled for subtalar screw arthroereisis surgery. Radiographs in the lateral and anteroposterior (AP) views were assessed independently in the single-leg and both-leg standing positions. Static pedobarography was performed as that for measuring weight-bearing. Standardized radiographic angles and pedobarographic data were analysed and correlated. RESULTS:There were differences in radiographic measurements between the single-leg and both-leg standing positions, including the AP talocalcaneal angle (p = 0.032), AP talus-first metatarsal base angle (p = 0.003), AP talus-first metatarsal angle (p = 0.003), lateral calcaneal pitch angle (p = 0.001), talus-first metatarsal index (p = 0.004), and talocalcaneal index (p = 0.029). Moreover, differences between these two standing modalities were found in most of the static pedobarographic data, including the contact area (p = 0001), maximal force (p = 0.001), and peak pressure (p = 0.007). Overall, medial foot pressure increased more in both-leg standing than in the single-leg standing position, whereas radiographic measurements showed a more pronounced flatfoot deformity in the single-leg standing position. The AP talus-first metatarsal angle was the only angle or index with a significant association to some pedobarographic measurements in both standing modalities. SIGNIFICANCE:As there are significant differences between single-leg standing and both-leg standing radiographic and static pedobarographic values, observers have to be precise in the definition of "weight-bearing" to gain reproducible and comparable study values in children and adults. We recommend acquiring both-leg standing foot radiographs because children with flexible flatfeet can stand more steadily in this position than in the single-leg standing position. 10.1016/j.gaitpost.2022.01.009
Crank-shaped arthrodesis for a flatfoot with a bipartite navicular: a case report. Tanaka Yasuhito,Takakura Yoshinori,Omokawa Shohei,Kumai Tsukasa,Sugimoto Kazuya Foot & ankle international 10.1177/107110070602700914
Can an insole for obese individuals maintain the arch of the foot against repeated hyper loading? BMC musculoskeletal disorders BACKGROUND:Insoles are often applied as preventive therapy of flatfoot deformity, but the therapeutic effects on obese individuals are still controversial. We aimed to investigate the effect of insole use on time-dependent changes in the foot arch during a repeated-loading simulation designed to represent 20,000 contiguous steps in individuals with a BMI value in the range of 30-40 kg/m. METHODS:Eighteen cadaveric feet were randomly divided into the following three groups: normal, obese, and insole. Ten thousand cyclic loadings of 500 N (normal group) or 1000 N (obese and insole groups) were applied to the feet. We measured time-dependent change in arch height and calculated the bony arch index (BAI), arch flexibility, and energy absorption. RESULTS:The normal group maintained more than 0.21 BAI, which is the diagnostic criterion for a normal arch, throughout the 10,000 cycles; however, BAI was less than 0.21 at 1000 cycles in the obese group (mean, 0.203; 95% confidence interval [CI] 0.196-0.209) and at 6000 cycles in the insole group (mean, 0.200; 95% CI, 0.191-0.209). Although there was a significant time-dependent decrease in flexibility and energy absorption in both the obese and insole groups (P < 0.001), the difference between 1 and 10,000 cycles were significantly smaller in the insole group than in the obese group (P = 0.024). CONCLUSIONS:Use of insoles for obese individuals may help to slow time-dependent foot structural changes. However, the effect was not enough to maintain the foot structure against repeated hyper loadings. 10.1186/s12891-019-2819-2
Talonavicular arthrodesis for the treatment of neurological flat foot deformity in pediatric patients. Shah Hitesh H Journal of pediatric orthopedics 10.1097/BPO.0b013e318286c194
The use of orthotic devices in adult acquired flatfoot deformity. Noll K H Foot and ankle clinics PTT dysfunction is the most common cause of adult acquired flat foot deformity. The aggressive nonoperative approach has become accepted more widely, in part because of the advances in orthotic and bracing technology and options. Many patients with a PTT dysfunction can be treated effectively with conservative management protocols. The goal of alleviating pain and correcting deformities is being accomplished with the proper application of the wide spectrum of orthotic modalities available today. 10.1016/s1083-7515(03)00077-9
Medial Column Fusions in Flatfoot Deformities: Naviculocuneiform and Talonavicular. Foot and ankle clinics Progressive collapsing foot deformity (PCFD; commonly referred to as flatfoot deformity) is a complex condition classically characterized by hindfoot valgus, midfoot abduction, and forefoot varus. Medial column arthrodesis can be used to reliably correct severe, arthritic, and unstable PCFD involving the medial column. Although both naviculocuneiform arthrodesis and talonavicular arthrodesis have their own indications, patient selection and careful radiographic and clinical assessment are crucial for any medial column arthrodesis. Herein, the authors discuss the indications for medial column arthrodesis procedures, outcomes as reported in the literature, and several case examples using medial column arthrodesis in deformity correction. 10.1016/j.fcl.2022.08.006
Adult Acquired Flatfoot Deformity: Anatomy, Biomechanics, Staging, and Imaging Findings. Flores Dyan V,Mejía Gómez Catalina,Fernández Hernando Moisés,Davis Michael A,Pathria Mini N Radiographics : a review publication of the Radiological Society of North America, Inc Adult acquired flatfoot deformity (AAFD) is a common disorder that typically affects middle-aged and elderly women, resulting in foot pain, malalignment, and loss of function. The disorder is initiated most commonly by degeneration of the posterior tibialis tendon (PTT), which normally functions to maintain the talonavicular joint at the apex of the three arches of the foot. PTT degeneration encompasses tenosynovitis, tendinosis, tendon elongation, and tendon tearing. The malaligned foot is initially flexible but becomes rigid and constant as the disorder progresses. Tendon dysfunction commonly leads to secondary damage of the spring ligament and talocalcaneal ligaments and may be associated with injury to the deltoid ligament, plantar fascia, and other soft-tissue structures. Failure of multiple stabilizers appears to be necessary for development of the characteristic planovalgus deformity of AAFD, with a depressed plantar-flexed talus bone, hindfoot and/or midfoot valgus, and an everted flattened forefoot. AAFD also leads to gait dysfunction as the foot is unable to change shape and function adequately to accommodate the various phases of gait, which require multiple rapid transitions in foot position and tone for effective ambulation. The four-tier staging system for AAFD emphasizes physical examination findings and metrics of foot malalignment. Mild disease is managed conservatively, but surgical procedures directed at the soft tissues and/or bones become necessary and progressively more invasive as the disease progresses. Although much has been written about the imaging findings of AAFD, this article emphasizes the anatomy and function of the foot's stabilizing structures to help the radiologist better understand this disabling disorder. RSNA, 2019. 10.1148/rg.2019190046
Effects of Kinesio tape on supporting medial foot arch in runners with functional flatfoot: a preliminary study. Siu Weng-Sam,Shih Yi-Fen,Lin Hsiu-Chen Research in sports medicine (Print) This study aimed to evaluate the anti-pronation effects of Kinesio tape on flexible flatfoot during running. Nine volunteers participated in a crossover trail of two conditions: with Kinesio tape (KT) or without taping (NT). The running consisted of 9 stages of different inclines on a treadmill over 28 minutes. Navicular drop distance (NDD) was measured before and after the running. Electromyography, the relative plantar pressure, Rating of Perceived Exertion and Visual Analogue Scale were recorded at each stage. After the application of Kinesio tapes over the tibialis posterior and transverse arch, the NDD reduced significantly and the relative posterior pressure reduced during stage 8. Without taping, the NDD decreased slightly after exercise. Comparing between conditions, the tibialis anterior were more activated with Kinesio tape in stages 4 and 5. During the latter half of the running, the medial gastrocnemius and peroneus longus reduced their activity in the KT and NT conditions respectively. In conclusion, the Kinesio tapes intended to facilitate the tibialis posterior and reinforce the transverse arch can reduce NDD in individuals with flexible flatfoot immediately after application, and increase muscle activity of their tibialis anterior during the first 15 minutes of the running. 10.1080/15438627.2019.1638258
Current concept review: acquired adult flatfoot deformity. Pinney Stephen J,Lin Sheldon S Foot & ankle international 10.1177/107110070602700113
Biomechanical evaluation of the efficacy of external stabilizers in the conservative treatment of acquired flatfoot deformity. Imhauser Carl W,Abidi Nicholas A,Frankel David Z,Gavin Kenneth,Siegler Sorin Foot & ankle international This study quantified and compared the efficacy of in-shoe orthoses and ankle braces in stabilizing the hindfoot and medial longitudinal arch in a cadaveric model of acquired flexible flatfoot deformity. This was addressed by combining measurement of hindfoot and arch kinematics with plantar pressure distribution, produced in response to axial loads simulating quiet standing. Experiments were conducted on six fresh-frozen cadaveric lower limbs. Three conditions were tested: intact-unbraced; flatfoot-unbraced; and flatfoot-braced. Flatfoot deformity was created by sectioning the main support structures of the medial longitudinal arch. Six different braces were tested including two in-shoe orthoses, three ankle braces and one molded ankle-foot orthosis. Our model of flexible flatfoot deformity caused the calcaneus to evert, the talus to plantarflex and the height of the talus and medial cuneiform to decrease. Flexible flatfoot deformity caused a pattern of medial shift in plantar pressure distribution, but minimal change in the location of the center of pressure. Furthermore, in-shoe orthoses stabilized both the hindfoot and the medial longitudinal arch, while ankle braces did not. Semi-rigid foot and ankle orthoses acted to stabilize the medial longitudinal arch. Based on these results, it was concluded that treatment of flatfoot deformity should at least include use of in-shoe orthoses to partially restore the arch and stabilize the hindfoot. 10.1177/107110070202300809
Office-based management of adult-acquired flatfoot deformity. Miniaci-Coxhead Sara Lyn,Flemister Adolph Samuel The Medical clinics of North America Adult-acquired flatfoot deformity is associated with dysfunction of the posterior tibial tendon, leading to loss of the medial arch. Patients tend to present with medial pain and swelling, but later in the disease process can also present with lateral-sided pain. The mainstay of nonoperative treatment is nonsteroidal anti-inflammatory drugs, weight loss, and orthotic insoles or brace use. The goals of therapy are to provide relief of symptoms and prevent progression of the deformity. If nonoperative management fails, a variety of surgical procedures are available; however, these require a lengthy recovery, and therefore patients should be advised accordingly. 10.1016/j.mcna.2013.10.006
Evaluation of hyperpronation and pes planus in adults. Gould N Clinical orthopaedics and related research Pes planus and hyperpronation of the hindfoot and midfoot are differentiated, and the numerous methods available for the clinical evaluation of both (including their norms) in the adult are presented. Pedotopography, a moiré fringe technique, is currently used in the clinical evaluation, along with "eyeball" visualization, tape measurement, ink mats, and roentgenography. Static deformities of the lower limbs and their joints are frequently responsible for manifestations of hyperpronation in the feet. Trauma and disease to bone, joints, or tendons in the region of the hindfoot or ankle can result in spastic pes planus with hyperpronation. Hyperpronation (excessive medial rotation of the talus) may exist without pes planus, but pes planus rarely is present without some degree of hyperpronation.
Letter Regarding: First-Ray Radiographic Changes After Flexible Adult Acquired Flatfoot Deformity Correction. Foot & ankle international 10.1177/10711007221077054
The Relationship Between Accessory Navicular and Flat Foot: A Radiologic Study. Park Hoon,Hwang Jin Ho,Seo Joon Oh,Kim Hyun Woo Journal of pediatric orthopedics BACKGROUND:The aim of this study was to investigate the relationship between accessory navicular (AN) and flat foot and to evaluate the association between flat foot and the symptoms of patients with AN. METHODS:We enrolled 196 patients with painful or asymptomatic AN in this study. Patients who were older than 18 years or who had no weight-bearing radiographs of the feet were not included. Another 46 normal participants were used as a control group. The AN group was divided into 3 subgroups: a group with asymptomatic AN; a symptomatic group that had not undergone excision; and a symptomatic group that had undergone surgery. Seven radiographic indices were measured including calcaneal pitch angle, tibiocalcaneal angle, talocalcaneal angle, naviculocuboid overlap, talonavicular coverage angle, lateral talo-first metatarsal angle, and AP talo-first metatarsal angle. Groups were compared regarding age, sex, presence of pain at the time of surgery, and radiographic parameters. RESULTS:The calcaneal pitch angle in the AN group was significantly smaller than that of controls (P=0.004). Naviculocuboid overlap (P=0.001), talonavicular coverage angle (P<0.001), lateral talo-first metatarsal angle (P=0.014), and AP talo-first metatarsal angle (P<0.001) were significantly larger in the AN group than in controls. No significant radiologic differences were seen between patients with symptomatic and asymptomatic AN. No significant radiographic differences were found between the groups of patients who had and who had not had bone excised. CONCLUSIONS:AN associated with radiographic parameters felt to be representative of a flat foot; however, the degree of flat foot was not associated with the development and severity of symptoms in patients with AN. 10.1097/BPO.0000000000000359
The contribution of the medial calcaneal osteotomy to the correction of flatfoot deformities. Nyska M,Parks B G,Chu I T,Myerson M S Foot & ankle international HYPOTHESES/PURPOSE:The success of the medial displacement calcaneal osteotomy in correcting flatfoot deformities is likely to be the result of a shift of the Achilles tendon forces on the hindfoot. The purpose of this study was twofold: 1) to define the contribution of the Achilles tendon to the flatfoot deformity, and 2) to define the effect of a calcaneal medial displacement osteotomy. METHODS:We used six different experimental dynamic stages: 1) intact foot without Achilles loading; 2) intact foot with Achilles loading; 3) flatfoot without medial calcaneal displacement osteotomy and without Achilles loading; 4) flatfoot without medial calcaneal displacement osteotomy but with Achilles loading; 5) flatfoot with medial calcaneal displacement osteotomy but without Achilles loading; and 6) flatfoot with medial calcaneal displacement osteotomy and with Achilles loading. The experimental flaffoot was developed by releasing the posterior tibial tendon, spring ligament, and plantar fascia and applying 7,000 cycles of axial fatigue load (range, 700 to 1,400 N; 1-Hz frequency). To simulate the phase of midstance, the peroneus longus, peroneus brevis, flexor digitorum longus, and flexor hallucis longus tendons were grasped by clamps, connected to pneumatic actuators, and loaded with precalculated forces. Anteroposterior and lateral radiographs were obtained for each stage on which the following measurements were made: talonavicular coverage angle, talar-first metatarsal angle, talocalcaneal angle, and height of the medial cuneiform. These measurements were compared with a one-way ANOVA. RESULTS:Between stages 1 and 2, all measurements were statistically insignificant. Between stages 3 and 4, for all measurements, Achilles tendon loading aggravated the flatfoot deformity (p < 0.05). After medial calcaneal osteotomy (stages 5 and 6), the Achilles tendon contributed less to the arch-flattening. We found that the medial displacement osteotomy plays an important role in reducing and/or delaying the progress of flatfoot deformity. CONCLUSIONS/SIGNIFICANCE:In the flatfoot, loading of the Achilles tendon increases the deformity. Medial calcaneal osteotomy significantly decreases the arch-flattening effect of this tendon and therefore limits the potential increase of the deformity. 10.1177/107110070102200402
Radiographic measurements of the talus and calcaneus in the adult pes planus foot type. Agoada David,Kramer Patricia Ann American journal of physical anthropology OBJECTIVE:A distinctive feature of the modern human foot is the presence of a medial longitudinal arch when weight-bearing. Although the talus and calcaneus play a major role in the structure and function of the human foot, the association between the morphology of these bones and longitudinal arch height has not been fully investigated. A better understanding of this relationship may assist in the interpretation of pedal remains of fossil hominins, where features of the foot and ankle morphology have been described as providing evidence for the presence of a longitudinal arch. METHODS:For this study, weight-bearing radiographs of 103 patients from an urban US Level 1 trauma center, taken as part of a clinical examination for medical evaluation, were selected. These radiographs were classified as to foot type by arch height as defined using the calcaneal inclination angle. From this group, 68 radiographs were suitable for linear and angular measurements of the talus and 74 of the calcaneus. The relationships between these measurements and arch height were explored using least squared linear regression analysis. RESULTS:The results demonstrate that angular measurements of the calcaneus (particularly those that reflect the relationship of the talar articular facets to each other and the tilt of the calcaneocuboid joint to the longitudinal axis of the calcaneus) are predictive of arch height (r = .29-.44 p ≤ .001). All angular measurements of the talus and all examined linear measurements of both the talus and calcaneus were not predictive of arch height. DISCUSSION:These results suggest that certain angular measurements of the calcaneus are associated with arch height in the modern human foot. While this information is useful in the interpretation of hominin pedal remains, the relationship of the morphology of these bones, as well as other bones of the foot, to arch height is complex, requiring further investigation. 10.1002/ajpa.23994
The Plantar Fascia Talar Head Correlation: A Radiographic Parameter With a Distinct Threshold to Validate Flatfoot Deformity and Its Corrective Surgery on Conventional Weightbearing Radiographs. Foot & ankle international BACKGROUND:Corrective surgery for flexible flatfoot deformity (FD) remains controversial, and one of the main reasons for this is the lack of standardized radiographic measurements to define an FD. Previously published radiographic parameters to differentiate between a foot with and without an FD do not have a commonly accepted and distinct threshold. METHODS:The plantar fascia-talar head correlation (PTC) with its defined threshold was assessed by measuring the distance between the medial border of the plantar fascia and the center of the talar head (DPT) on conventional dorsoplantar and lateral weightbearing radiographs; the authors were blinded to the clinical diagnosis of the 189 patients' first visits. Feet were sorted into groups with and without an FD based on their clinical examination. The effect of operative corrections of FD on the PTC was retrospectively evaluated on an additional 38 patients. RESULTS:The sensitivity of the PTC was 0.98 (95% CI: 0.9-1) and specificity 0.96 (95% CI: 0.92-0.98), respectively, to identify an FD, consistent with the clinical examination. Thirty-five of 38 surgeries sufficiently corrected the FD and the PTC comparable to that in subjects without an FD. Three corrections with a residual FD did not adequately correct the PTC. CONCLUSION:The PTC is a reliable radiographic parameter with a distinct threshold that is sensitive and specific for the differentiation of feet with and without an FD including feet with and without residual FD after corrective surgery. The PTC is applicable to monitor the needed intraoperative amount of correction using simulated weightbearing fluoroscopy. LEVEL OF EVIDENCE:Level III, diagnostic. 10.1177/10711007211052258
Dynamic medial column stabilization using flexor hallucis longus tendon transfer in the surgical reconstruction of flatfoot deformity in adults. Kim Jaeyoung,Kim Ji-Beom,Lee Woo-Chun Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons BACKGROUND:A common challenge in flatfoot reconstruction arises when there are multiple locations of collapse within the medial column. An extension of arthrodesis may lead to complications such as stiffness or adjacent joint arthritis. The purpose of this study was to report outcomes of flatfoot reconstruction using the dynamic medial column stabilization (DMCS) technique, which transfers the flexor hallucis longus (FHL) tendon to the first metatarsal base to support the entire medial column. METHODS:We retrospectively reviewed 14 consecutive patients (14 feet) who underwent DMCS as an adjunct to flatfoot reconstruction. In all cases, a medial displacement calcaneal osteotomy and gastrocnemius recession were performed to address hindfoot valgus deformity and heel cord tightness, respectively. Deformity correction was assessed using preoperative and postoperative weightbearing radiographs. The newly defined metatarsal-cuneiform articular angle (MCAA) and naviculo-cuneiform articular angle (NCAA) were measured to assess correction at each medial column joints. Clinical outcomes included the FFI and VAS scores. Any complications related to the surgery were investigated. RESULTS:All radiographic parameters significantly improved postoperatively. The sagittal plane correction occurred at all three joints within the medial column. Clinically, both FFI and VAS improved significantly at the final follow-up. One patient developed plantar pain under the first metatarsal head that may have been associated with the overtightening of the transferred tendon. CONCLUSION:DMCS using FHL tendon transfer to the first metatarsal base was a useful technique for restoring the medial arch and correcting three planar deformities in the setting of flatfoot deformity. 10.1016/j.fas.2020.12.007
Response to "Letter Regarding: First-Ray Radiographic Changes After Flexible Adult Acquired Flatfoot Deformity Correction". Foot & ankle international 10.1177/10711007221077050
Immediate effects of silicone insoles on gait pattern in patients with flexible flatfoot. Kulcu Duygu Geler,Yavuzer Gunes,Sarmer Sercan,Ergin Sureyya Foot & ankle international BACKGROUND:Flatfoot in which a normal arch fails to develop is a common deformity in both children and adults. A frequently-used treatment is an over-the-counter insole to normalize foot mechanics and relieve pain. This study was designed to evaluate the effects of over-the-counter silicone insoles on the gait patterns of patients with flexible flatfoot. METHODS:Thirty-four adults (24 women and nine men, average age 43.7 +/- 9.7 years) with bilateral symptomatic flatfoot deformities were included in the study. Flatfoot was diagnosed by a lateral talometatarsal angle of more than 4 degrees and a talocalcaneal angle of more than 30 degrees. Three-dimensional gait analysis and video recordings were done at a single session. All patients walked at self-selected speeds over a 10-meter walkway with and without insoles. Time-distance parameters and kinematic and kinetic characteristics of gait in the sagittal plane were evaluated by a quantitative gait analysis system. RESULTS:Mean lateral talometatarsal and talocalcaneal angles were 6.3 +/- 2.5 degrees and 56.1 +/- 8.6 degrees, respectively. There was no difference in gait parameters with or without the insoles. CONCLUSIONS:Over-the-counter insoles have no beneficial effect in normalizing forces acting on the foot and on the entire lower extremity in adults with flexible flatfoot. 10.3113/FAI.2007.1053
Plantar pressure and radiographic changes after distal calcaneal lengthening in children and adolescents. Davitt J S,MacWilliams B A,Armstrong P F Journal of pediatric orthopedics Eleven feet (nine patients) with symptomatic flatfoot deformities of various etiologies that had failed nonoperative treatment underwent distal calcaneal lengthenings. Pre- and postoperative plantar pressure measurements and radiographic parameters were compared and a postoperative clinical evaluation was performed using the AOFAS ankle and hindfoot scoring system. Follow-up ranged from 4 to 20 months (mean, 11.1 months). Plantar pressure parameters including contact area, mean, and peak pressures indicated significant lateral shifts in the weight-bearing surface of the foot. The most significant radiographic changes were an improvement in the talonavicular coverage angle (mean, 17.3 degrees) on the anteroposterior view and an improvement in the talo-first metatarsal angle (16.2 degrees) on the lateral view. The average postoperative American Orthopedic Foot and Ankle Society score was 90 with seven excellent, three good, and one poor results.
Valgus malalignment: what joints to address? Kadakia Anish R Foot & ankle international 10.3113/FAI.2012.0161
Calcaneal osteotomy for hindfoot deformity. Orthopaedics & traumatology, surgery & research : OTSR Calcaneal osteotomy is an extra-articular procedure used for conservative surgical treatment of hindfoot deformity. It has static, architectural and dynamic effects, reorienting the tuberosity action point of the digastric muscle formation of the sural triceps and plantar aponeurosis. Calcaneal osteotomies vary in location, form and displacement, but can be categorized as tuberosity osteotomy, acting on talar position, and cervical osteotomy, acting on Chopart joint-line orientation. We here describe the 3 main calcaneal osteotomies we use for hindfoot deformity: talar varus/valgus, valgus flatfoot, and midfoot abductus/adductus. In each case, we describe our technique, resulting from our responses to the difficulties we have had to deal with: medializing osteotomy: performed percutaneously to limit skin complications, and easily associated to cervical calcaneal osteotomy to manage valgus flatfoot; Hintermann cervical adduction osteotomy: providing excellent angular correction, while conserving a medial cortical hinge; lateralizingosteotomy: performed on a medial approach, to enhance translation capacity and prevent the acute tarsal tunnel syndrome with which we have been otherwise confronted. Correcting foot deformities involves complex, multi-dimensional, multi-tissue surgery that is risky as it concerns a segment with terminal vascularization. The present three techniques need to be mastered, as they are usually associated to other tendon and/or ligament reconstruction procedures, and tourniquet time is limited. LEVEL OF EVIDENCE: V; expert opinion. 10.1016/j.otsr.2021.103121
Weight-bearing radiographs and cone-beam computed tomography examinations in adult acquired flatfoot deformity. Shakoor Delaram,de Cesar Netto Cesar,Thawait Gaurav K,Ellis Scott J,Richter Martinus,Schon Lew C, ,Demehri Shadpour Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons BACKGROUND:Optimal characterization of Adult acquired flatfoot deformity (AAFD) on two-dimensional radiograph can be challenging. Weightbearing Cone Beam CT (CBCT) may improve characterization of the three-dimensional (3D) structural details of such dynamic deformity. We compared and validated AAFD measurements between weightbearing radiograph and weightbearing CBCT images. METHODS:20 patients (20 feet, right/left: 15/5, male/female: 12/8, mean age: 52.2) with clinical diagnosis of flexible AAFD were prospectively recruited and underwent weightbearing dorsoplantar (DP) and lateral radiograph as well as weightbearing CBCT. Two foot and ankle surgeons performed AAFD measurements at parasagittal and axial planes (lateral and DP radiographs, respectively). Intra- and Inter-observer reliabilities were calculated by Intraclass correlation (ICC) and Cohen's kappa. Mean values of weightbearing radiograph and weightbearing CBCT measurements were also compared. RESULTS:Except for medial-cuneiform-first-metatarsal-angle, adequate intra-observer reliability (range:0.61-0.96) was observed for weightbearing radiographic measurements. Moderate to very good interobserver reliability between weightbearing radiograph and weightbearing CBCT measurements were observed for the following measurements: Naviculocuneiform-angle (ICC:0.47), Medial-cuneiform-first-metatarsal-gapping (ICC:0.58), cuboid-to-floor-distance (ICC:0.68), calcaneal-inclination-angle(ICC:0.7), axial Talonavicular-coverage-angle(ICC:0.56), axial Talus-first-metatarsal-angle(ICC:0.62). Comparing weightbearing radiograph and weightbearing CBCT images, statistically significant differences in the mean values of parasagittal talus-first-metatarsal-angle, medial-cuneiform-first-metatarsal-angle, medial-cuneiform-to-floor-distance and navicular-to-floor-distance was observed (P < 0.05). CONCLUSION:Moderate to very good correlation was observed between certain weightbearing radiograph and weightbearing CBCT measurements, however, significant difference was observed between a number of AAFD measurements, which suggest that 2D radiographic evaluation could potentially underestimate the severity of AAFD, when compared to 3D weightbearing CT assessment. 10.1016/j.fas.2020.04.011
Understanding the role of foot biomechanics on regional foot orthosis deformation in flatfoot individuals during walking. Hajizadeh Maryam,Desmyttere Gauthier,Ménard Anne-Laure,Bleau Jacinte,Begon Mickael Gait & posture BACKGROUND:Foot orthoses (FOs) are one of the most common interventions to restore normal foot mechanics in flatfoot individuals. New technologies have made it possible to deliver customized FOs with complex designs for potentially better functionalities. However, translating the individuals' biomechanical needs into the design of customized FOs is not yet fully understood. RESEARCH QUESTION:Our objective was to identify whether the deformation of customized FOs is related to foot kinematics and plantar pressure during walking. METHODS:The kinematics of multi-segment foot and FOs contour were recorded together with plantar pressure in 17 flatfoot individuals while walking with customized FOs. The deformation of FOs surface was predicted from its contour kinematics using an artificial neural network. Plantar pressure map and deformation were divided into five anatomically based regions defined by the corresponding foot segments. Forward stepwise linear mixed models were built for each of the four gait phases to determine the feet-FOs interaction. RESULTS:It was observed that some associations existed between foot kinematics and pressure with regional FOs deformation. From heel-strike to foot-flat, longitudinal arch angle was associated with FOs deformation in forefoot. From foot-flat to midstance, rearfoot eversion accounted for variation in the deformation of medial FOs regions, and forefoot abduction for the lateral regions. From midstance to heel-off, rearfoot eversion, longitudinal arch angle, and plantar pressure played significant role in deformation. Finally, from heel-off to toe-off, forefoot adduction affected the deformation of forefoot and midfoot. SIGNIFICANCE:This study provides guidelines for designing customized FOs. Flatfoot individuals with excessive rearfoot eversion or very flexible medial arches require more support on medial FOs regions, while the ones with excessive forefoot abduction need the support on lateral regions. However, a compromise should be made between the level of support and the level of increase in plantar pressure to avoid stress on foot structures. 10.1016/j.gaitpost.2021.10.015
Optimal Position of the Heel Following Reconstruction of the Stage II Adult-Acquired Flatfoot Deformity. Conti Matthew S,Ellis Scott J,Chan Jeremy Y,Do Huong T,Deland Jonathan T Foot & ankle international BACKGROUND:While previous work has demonstrated a linear relationship between the amount of medializing calcaneal osteotomy (MCO) and the change in radiographic hindfoot alignment following reconstruction, an ideal postoperative hindfoot alignment has yet to be reported. The aim of this study was to identify an optimal postoperative hindfoot alignment by correlating radiographic alignment with patient outcomes. METHODS:Fifty-five feet in 55 patients underwent flatfoot reconstruction for stage II adult-acquired flatfoot deformity (AAFD) by 2 fellowship-trained foot and ankle orthopedic surgeons. Hindfoot alignment was determined as previously described by Saltzman and el-Khoury.(23) Changes in pre- and postoperative scores in each Foot and Ankle Outcome Score (FAOS) subscale were calculated for patients in postoperative hindfoot valgus (≥0 mm valgus, n = 18), mild varus (>0 to 5 mm varus, n = 17), and moderate varus (>5 mm varus, n = 20). Analysis of variance and post hoc Tukey's tests were used to compare the change in FAOS results between these 3 groups. RESULTS:At 22 months or more postoperatively, patients corrected to mild hindfoot varus showed a significantly greater improvement in the FAOS Pain subscale compared with patients in valgus (P = .04) and the Symptoms subscale compared with patients in moderate varus (P = .03). Although mild hindfoot varus did not differ significantly from moderate varus or valgus in the other subscales, mild hindfoot varus did not perform worse than these alignments in any FAOS subscale. No statistically significant correlations between intraoperative MCO slide distances and FAOS subscales were found. CONCLUSIONS:Our study indicates that correction of hindfoot alignment to between 0 and 5 mm of varus on the hindfoot alignment view (clinically a straight heel) following stage II flatfoot reconstruction was associated with the greatest improvement in clinical outcomes following hindfoot reconstruction in stage II AAFD. LEVEL OF EVIDENCE:Level III, comparative series. 10.1177/1071100715576918
Tibialis anterior rerouting combined with calcaneal lengthening osteotomy as a single-stage reconstruction of symptomatic flexible flatfoot in children and adolescents. Journal of orthopaedic surgery and research BACKGROUND:Symptomatic flexible flatfoot in children and adolescents should be surgically managed only if conservative measures have failed. The aim of this study was to assess functional and radiological results of tibialis anterior rerouting combined with calcaneal lengthening osteotomy as s single-stage reconstruction of symptomatic flexible flatfoot. METHODS:The current study was a prospective study of patients with symptomatic flexible flatfoot treated by single-stage reconstruction in the form of tibialis anterior tendon rerouting combined with calcaneal lengthening osteotomy. The American Orthopaedic Foot and Ankle Society score (AOFAS) was utilized to evaluate the functional outcomes. The evaluated radiological parameters included the standing anteroposterior (AP) and lateral talo-first metatarsal angle, talar head coverage angle, and calcaneal pitch angle. RESULTS: The current study included 16 patients (28 feet) with a mean age of 11.6 ± 2.1 years. There was a statistically significant improvement in the mean AOFAS score from 51.6 ± 5.5 preoperatively to 85.3 ± 10.2 at final follow-up. Postoperatively, there was a statistically significant reduction in the mean AP talar head coverage angle from 13.6 ± 4.4° to 3.9 ± 3°, the mean AP talo-first metatarsal angle from 16.9 ± 4.4° to 4.5 ± 3.6°, and the mean lateral talo-first metatarsal angle from 19.2 ± 4.9° to 4.6 ± 3.2°, P < 0.001. Additionally, the mean calcaneal pitch angle increased significantly from 9.6 ± 1.9° to 23.8 ± 4.8°, P < 0.001. Superficial wound infection occurred in three feet and was treated adequately by dressing and antibiotics. CONCLUSION: Symptomatic flexible flatfoot in children and adolescents can be treated with combined lateral column lengthening and tibialis anterior rerouting with satisfactory radiological and clinical outcomes. Level of evidence Level IV. 10.1186/s13018-023-03890-7
Calcaneocuboid joint pressure after lateral column lengthening in a cadaveric planovalgus deformity model. Momberger N,Morgan J M,Bachus K N,West J R Foot & ankle international The purpose of this study is twofold: first, to measure the joint contact pressure across the calcaneocuboid joint in a planovalgus deformity and compare the results to pressures measured in a normal foot; and second, to determine the change in pressure across the calcaneocuboid joint after an Evan's-type calcaneal lengthening osteotomy. The effect of this procedure on the calcaneocuboid joint was evaluated using seven cadaver feet to measure peak pressure across the calcaneocuboid joint under a constant load. Each foot was sectioned medially to reproduce a deformity consistent with an adult, acquired flatfoot. Each flatfoot deformity was then corrected using a ten-millimeter lateral column lengthening osteotomy. Joint pressures were measured in the normal foot, the created flatfoot and then in the corrected flatfoot. Peak pressures across the joint increased significantly from baseline in the flatfoot (p <0.05). However, the change in pressure from the flatfoot to the corrected foot was not significant, and in some cases peak pressures in the corrected foot were actually lower than in the flatfoot. These findings indicate that calcaneal lengthening through an Evan's osteotomy does not increase pressure across the calcaneocuboid joint beyond physiologic loads in the flatfoot. 10.1177/107110070002100903
Medial double arthrodesis with lateral column sparing and arthrodiastasis: a radiographic and medical record review. Berlet Gregory C,Hyer Christopher F,Scott Ryan T,Galli Melissa M The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons Correction of valgus hindfoot deformity can be successfully achieved with arthrodesis of the subtalar and talonavicular joints through a single medial based incision. The advantages of medial double arthrodesis compared with the standard triple arthrodesis 2-incision approach include the absence of a lateral incision and a few degrees of residual mobility through the unfused calcaneocuboid joint (CCJ). The CCJ has often been noted to distract and decompress with the abduction correction achieved through medial double fusion. The primary goal of the present retrospective study was to identify the frequency of CCJ decompression, measure the radiographic changes at the CCJ, and evaluate the flatfoot correction using this operative approach. A total of 46 patients (47 feet) were identified as possible subjects. Twenty patients (20 feet) with a mean follow-up period of 9.2 ± 4.1 (range 6 to 21) months met our inclusion criteria. Distraction of the CCJ using medial double fusion resulted in increased joint space and improvement of at least 1 grade of arthritis in 50% of the patients. In the patients with severe CCJ arthrosis, the improvement was less predictable, with only 20% showing radiographic improvement. Correction of flatfoot as measured on standard radiographs showed excellent results. Subchondral bone changes as measured by the CCJ arthrosis scale improved in patients with mild to moderate arthritis after distraction arthrodiastasis. However, those with severe preoperative CCJ had less predictable improvement. Medial double arthrodesis for severe flatfoot deformity provides predictable correction of the deformity and improvement in the CCJ arthritis scale when the preoperative arthritis of the CCJ is mild to moderate. 10.1053/j.jfas.2014.10.012
Biomechanics and clinical analysis of the adult acquired flatfoot. Richie Douglas H Clinics in podiatric medicine and surgery The adult acquired flatfoot is a deformity that results from the loss of dynamic and static supportive structures of the medial longitudinal arch. The severity of the deformity is dependent upon the role of ligamentous disruption on the hindfoot that can be determined by careful clinical examination. Treatment of the adult flatfoot requires an understanding of the biomechanical effects of deforming forces, tendon dysfunction, ligament disruption, and joint sublaxation. 10.1016/j.cpm.2007.07.003
Subtalar arthrodesis with flexor digitorum longus transfer and spring ligament repair for treatment of posterior tibial tendon insufficiency. Johnson J E,Cohen B E,DiGiovanni B F,Lamdan R Foot & ankle international The surgical treatment of flexible pes planovalgus deformities resulting from Stage 2 posterior tibial tendon insufficiency is controversial and many techniques have been proposed. We retrospectively reviewed the results of subtalar arthrodesis combined with spring ligament repair/reefing and flexor digitorum longus (FDL) transfer to the navicular. There were sixteen patients (seventeen feet) with an average follow-up of 27 months (9-52). All deformities were passively correctable. The average age was 56 yrs (39-78). All patients had failed conservative management, 88% had previously been treated with orthotics, and 53% had lateral pain from subfibular impingement. Two patients were noted to have degenerative changes of the subtalar joint. Successful subtalar joint fusion occurred in all patients with an average time to radiographic union of 10.1 weeks (5-24). The average AOFAS hindfoot score and Maryland foot score postoperatively was 82 and 86 respectively. Standing radiographic analysis demonstrated an average improvement in the AP talo-1st metatarsal angle of 6 degrees (24 degrees preoperative, 18 degrees postoperative). The talonavicular coverage angle improved an average of 17 degrees (34 degrees preoperative, 17 degrees postoperative). The lateral talo-1st metatarsal angle improved an average of 10 degrees (18 degrees preoperative, 8 degrees postoperative). The lateral talocalcaneal angle decreased an average of 21o (55 degrees preoperative, 34 degrees postoperative). The distance of the medial cuneiform to the floor on the lateral radiograph averaged 12mm preoperatively and 18mm postoperatively (avg. improvement 6mm). The combination of the flexor digitorum longus tendon transfer and spring ligament repair with subtalar arthrodesis is an effective and reliable procedure which provides excellent correction of hindfoot valgus as well as forefoot abduction and restoration of the height of the longitudinal arch. These results compare favorably with flexor transfer combined with either calcaneal osteotomy or lateral column lengthening. 10.1177/107110070002100902
Talocalcaneal and subfibular impingement in symptomatic flatfoot in adults. Malicky Eric S,Crary Jay L,Houghton Michael J,Agel Julie,Hansen Sigvard T,Sangeorzan Bruce J The Journal of bone and joint surgery. American volume BACKGROUND:Patients with symptomatic flatfoot deformity often present with pain in the lateral part of the hindfoot. The cause of this pain has not been clearly established. Impingement between the talus and the calcaneus or between the calcaneus and the fibula has been suggested as a cause but has not been documented. METHODS:We examined the computed tomographic scans, performed with simulated weight-bearing, of nineteen adult patients with symptomatic flatfoot to determine the potential causes of pain in the lateral aspect of the foot. The scans were performed with use of a custom loading frame designed to simulate weight-bearing with the foot in a neutral position while a 75-N axial compressive load was applied. Four examiners independently examined the coronal images as well as sagittal plane reconstructions for direct (bone-on-bone contact) and indirect (subchondral sclerosis or cysts) evidence of (1) extra-articular contact between the talus and the calcaneus in the sinus tarsi and (2) contact between the calcaneus and the fibula. The data were compared with those from five scans of normal feet in neutral alignment. RESULTS:Overall, the prevalence of sinus tarsi impingement was 92% and the prevalence of calcaneofibular impingement was 66% in the flatfoot group versus 0% and 5%, respectively, in the control group. The study patients who had calcaneofibular impingement also had sinus tarsi impingement. There was substantial agreement among the examiners as to whether impingement was present. CONCLUSIONS:There appear to be two frequently occurring extra-articular sources of bone impingement in the lateral aspect of the hindfoot in adults with symptomatic severe flatfoot deformity. The impingement in the lateral aspect of the hindfoot may first occur within the sinus tarsi and then involve the calcaneofibular region. Cyst formation and/or sclerosis in this region that is visible on plain radiographs or on computed tomographic scans performed without weight-bearing should create suspicion of impingement. 10.2106/00004623-200211000-00015
Foot pressure and radiographic outcome measures of lateral column lengthening for pes planovalgus deformity. Oeffinger D J,Pectol R W,Tylkowski C M Gait & posture The purpose of this study was to establish and characterize the relationship between foot pressure analysis and radiographic measurements in children that underwent a lateral column lengthening procedure for pes planovalgus (PPV). Eight children (13 feet) with PPV that had failed non-operative treatment underwent a lateral column lengthening procedure. Pre-operative and post-operative standing AP and lateral radiographs and foot pressure data were obtained. The relationships between the radiographic and foot pressure measurements were investigated. The findings from this study demonstrated strong relationships between these parameters. The relationships seen in this study indicate that the addition of foot pressure analysis provides objective documentation of the improvement in foot pressure distribution following a lateral column lengthening. Also, there is a direct, positive relationship between the key radiographic and foot pressure measurements. 10.1016/s0966-6362(00)00075-8
The correlation between selected measurements from footprint and radiograph of flatfoot. Chen Chia-Hsin,Huang Mao-Hsiung,Chen Tien-Wen,Weng Ming-Cheng,Lee Chia-Ling,Wang Gwo-Jaw Archives of physical medicine and rehabilitation OBJECTIVES:To assess the subarch angle obtained from electronic footprints using a capacitive mat transducer system in children with flatfeet, to evaluate other foot arch indexes, and to compare the results with radiographic measurements. DESIGN:A cross-sectional study. SETTING:Rehabilitation clinic in a municipal hospital. PARTICIPANTS:Thirty-two children (age range, 7-13y) diagnosed with flatfeet. INTERVENTIONS:Radiographic measurements and foot shape measurements obtained from feet. MAIN OUTCOME MEASURES:Talo-first metatarsal angle, talocalcaneal angle, talo-horizontal angle, and calcaneal angle were obtained from radiographs. Subarch angle, arch indexes, and long plantar angle were all captured and calculated via a capacitive transducer plate. RESULTS:Correlations between the subarch angle and the talo-first metatarsal angle, talo-horizontal angle, and arch height were significant, as was the correlation between midfoot arch index and talo-horizontal angle. The forefoot arch index had no significant relationship with radiographic parameters. The talo-horizontal angle and arch height had significant relationships with the long plantar angle. CONCLUSIONS:Measurement of the subarch angle had significant correlation with the radiographic parameters in children with flatfeet and it was accurately and easily obtained from a capacitive forceplate. Measurement of the subarch angle can be a useful tool in the assessment and diagnosis of flatfoot. 10.1016/j.apmr.2005.10.014
Adult acquired flatfoot deformity. Treatment of dysfunction of the posterior tibial tendon. Mann R A The Journal of bone and joint surgery. American volume
New radiographic parameters assessing forefoot abduction in the adult acquired flatfoot deformity. Ellis Scott J,Yu Joseph C,Williams Benjamin R,Lee Cheol,Chiu Ya-Lin,Deland Jonathan T Foot & ankle international BACKGROUND:Stage II flatfoot secondary to posterior tibial tendon insufficiency may be subclassified into mild (IIa) and severe (IIb) deformity based on the degree of talonavicular abduction. Current assessment of this abduction is difficult. We hypothesized that two new anteroposterior radiographic parameters, the lateral talonavicular incongruency angle (IA) and incongruency distance (ID) would demonstrate good reliability, correlate with current abduction parameters, and differ in IIb deformity, IIa deformity, and controls. MATERIALS AND METHODS:Preoperative radiographs for consecutive patients undergoing flatfoot reconstruction were reviewed and subdivided into those with a Stage IIb (n = 32) or Stage IIa (n = 8) deformity. A third group of patients without flatfoot served as control (n = 30). Radiographs were measured blindly by two investigators. Reliability was assessed with intraclass correlation coefficients (ICC), correlation with existing parameters with Pearson coefficients, and comparison between groups with analysis of variance. RESULTS:The mean intrarater and interrater ICC's for the IA (0.88 and 0.81, respectively) were high. The IA correlated well with the coverage angle (r = 0.86) and uncoverage percent (r = 0.76). The IA was higher in the IIb versus IIa patients (p = 0.007) and in the IIb group versus control (p < 0.001). The ID demonstrated excellent reliability (ICC's of 0.83 and 0.83), but correlated poorly with the two other abduction parameters (r = -0.59 and -0.49) and failed to differentiate between the three groups (p = 0.0528). CONCLUSION:This data suggests that the IA is reliable and may help subclassify Stage II flatfoot deformity. 10.3113/FAI.2009.1168
Validation of a population of patient-specific adult acquired flatfoot deformity models. Spratley E Meade,Matheis Erika A,Hayes Curtis W,Adelaar Robert S,Wayne Jennifer S Journal of orthopaedic research : official publication of the Orthopaedic Research Society Adult acquired flatfoot deformity (AAFD) is a degenerative disease resulting in malalignment of the mid- and hindfoot secondary to posterior tibial tendon dysfunction and increasing implication of ligament pathologies. Despite the complex 3D nature of AAFD, 2D radiographs are still employed to diagnose and stage the disease. Computer modeling techniques allow for accurate 3D recreations of musculoskeletal systems for the investigation of biomechanical factors contributing to disease. Following Institutional Review Board approval, the lower limbs of six diagnosed AAFD sufferers were imaged with MRI, photographs, and X-ray. Next, a radiologist graded the MRI attenuation of eight soft-tissues implicated in AAFD. Six patient-specific rigid-body models were then created and loaded according to patient weight, graded soft-tissues, and extrinsic muscles. Model function was validated using clinically relevant kinematic measures in three planes. Agreement varied depending on the measure, with average absolute deviations of < 7° for angles and <4 mm for distances. Additionally, the clinically favored AP talonavicular coverage angle, ML talo-1st metatarsal angle, and ML 1st cuneiform height showed strong correlations of R(2) = 0.63, 0.75, and 0.85, respectively. Thus, computer modeling offers a promising methodology for the non-invasive investigation of in vivo kinematic behavior in pathologic feet and, once validated, may further be used to investigate biomechanical parameters that are difficult to measure clinically. 10.1002/jor.22471
Relationship between symptoms and weight-bearing radiographic parameters of idiopathic flexible flatfoot in children. Yan Gui-sen,Yang Zheng,Lu Ming,Zhang Jian-li,Zhu Zheng-hua,Guo Yuan Chinese medical journal BACKGROUND:Idiopathic flexible flatfoot in children most frequently improves with age and remains asymptomatic. It is a physiological variation of the normality that does not require treatment unless it becomes symptomatic. The aim of this research was to investigate the reason why some individuals with flexible flatfoot become symptomatic by analysis of the differences in the relative alignment of each segment of the foot between symptomatic and asymptomatic patients with idiopathic flexible flatfoot using radiographic measurements. METHODS:One hundred patients with idiopathic flexible flatfoot were retrospectively identified and divided into two groups: asymptomatic (n = 50) and symptomatic (n = 50). Standing anteroposterior and lateral radiographs of the foot were analyzed. Five measurements were calculated to describe the alignment of the foot. An independent-samples t-test and Logistic regression test were used for statistical analysis. RESULTS:Age and sex were similar in the two groups. The independent-samples test revealed significant differences in two parameters: the anteroposterior talonavicular coverage angle and the lateral talo-first metatarsal angle. When the Logistic regression test was performed, only the talonavicular coverage angle showed statistical significance. CONCLUSIONS:The lateral displacement of the navicular bone, measured by the anteroposterior talonavicular coverage angle, seems to be related to the onset of symptoms. In individuals with otherwise normal flexible flatfoot, an increase in this angle might be an important risk factor for developing symptoms.
Short-term radiographic analysis of operative correction of adult acquired flatfoot deformity. Iossi Michael,Johnson Jeffrey E,McCormick Jeremy J,Klein Sandra E Foot & ankle international BACKGROUND:Multiple procedures have been described to treat stage II (flexible) deformities driven by the clinical presence of "mild" versus "severe" deformity. The purpose of this study was to identify the radiographic correction after bony realignment procedures and to compare preoperative measures with postoperative measures to better understand the clinical application of these procedures. METHODS:Seventy-two feet in 68 patients treated for stage II deformity between January 1999 and December 2010 were available for retrospective chart review. The average age of the patients was 55 years, and final radiographs were evaluated at an average of 9 months postoperatively. All patients had a flexor digitorum longus transfer to the navicular and bony realignment. Radiographic parameters measured included lateral talus-first metatarsal angle, medial cuneiform-floor distance, calcaneal pitch, anteroposterior talus-second metatarsal angle, and talonavicular coverage angle. Differences in pre- and postoperative measurements and between group comparisons were analyzed. RESULTS:Three patient groups were identified: medial displacement calcaneal osteotomy (group 1), lateral column lengthening (group 2), and both medial displacement calcaneal osteotomy and lateral column lengthening (group 3). The lateral talus-first metatarsal angle mean difference was 5.1 degrees in group 1, 16.2 degrees in group 2, and 16.5 degrees in group 3. The talonavicular coverage angle mean difference was 5.7 degrees in group 1, 24.2 degrees in group 2, and 19.4 degrees in group 3. Changes in pre- to postoperative measures were statistically significant for all groups for the parameters measured. The pairwise group comparison revealed a statistically significant difference in the correction obtained in group 3 compared with that of group 1. CONCLUSION:Clinical and radiographic parameters are a consideration when choosing bony realignment procedures to reconstruct a flexible flatfoot deformity. In the treatment of more severe deformities, lateral column lengthening resulted in a greater radiographic improvement in alignment. A medial displacement osteotomy alone is also a valuable tool to correct these deformities although it provided a different level of correction compared with the lateral column lengthening. LEVEL OF EVIDENCE:Level III, comparative case series. 10.1177/1071100713475432
Three-dimensional analysis of flatfoot deformity: cadaver study. Kitaoka H B,Luo Z P,An K N Foot & ankle international Eleven fresh-frozen cadaver foot specimens were tested to define changes in tarsal alignment associated with flatfoot, or pes planus, a common clinical problem. The three-dimensional position of four bones (talus, calcaneus, navicular, and first metatarsal) relative to the fixed tibia was determined with a magnetic tracking system in the intact foot and flatfoot conditions. In the flatfoot, the average metatarsal-to-talar position difference was 11.7 degrees +/-4.4 degrees in abduction (P < 0.0001), 10.4 degrees +/-3.6 degrees in dorsiflexion (P < 0.0001), and 10.9 degrees +/-6.0 degrees in eversion (P < 0.0001) compared with the intact foot. The average calcaneal-to-talar position difference was 2.2 degrees +/-2.6 degrees in abduction (P=0.0171) and 2.7 degrees+/-2.0 degrees in eversion (P=0.0012) compared with the intact foot. The average navicular-to-talar position difference was 13.6 degrees +/-5.0 degrees in abduction (P < 0.0001), 10.5 degrees +/-6.6 degrees in dorsiflexion (P=0.0004), and 8.1 degrees +/-3.8 degrees in eversion (P < 0.0001) compared with normal. The average talar-to-tibial position difference was -8.2 degrees +/-3.2 degrees in dorsiflexion (P < 0.001) compared with the intact foot. The average arch height difference was 6.0+/-2.7 mm (P < 0.0001) less than the normal condition. The deformity associated with flatfoot is complex and occurs in multiple joints and in all three planes. An understanding of the normal and pathologic (flatfoot) conditions is necessary to surgically restore appropriate alignment and function in hindfoot reconstruction operations. 10.1177/107110079801900705
Effect of foot orthoses on tibialis posterior activation in persons with pes planus. Kulig Kornelia,Burnfield Judith M,Reischl Stephen,Requejo Susan Mais,Blanco Cesar E,Thordarson David B Medicine and science in sports and exercise PURPOSE:To examine the influence of footwear on tibialis posterior (TP) activation in persons with pes planus. METHODS:Six asymptomatic adults with pes planus (arch index of < or =0.16) participated. Subjects performed a resisted foot adduction with plantar flexion exercise (3 sets of 30 repetitions). The exercise was performed barefoot and shod with foot orthoses. The two testing conditions were separated by a week. Magnetic resonance image signal intensity of the tibialis posterior, tibialis anterior, soleus, medial gastrocnemius, and peroneus longus was measured immediately before and after each exercise. Multivariate analyses of variance followed by paired Student's t-test were performed for the signal intensity of each muscle assessed to determine whether TP was selectively activated during the barefoot and shod exercises. RESULTS:When barefoot, five of the six subjects activated other lower-leg muscles in addition to TP. When wearing the foot orthoses and shoes, all five participants activated only TP. Additionally, activation of TP was higher when exercises were performed in shoes with orthoses than when barefoot (P = 0.019). CONCLUSION:Wearing the foot orthoses and shoes improved selective activation of the TP in persons with flat feet. In cases where selective activation of TP is desirable, such as persons with flat feet or TP tendon dysfunction, use of shoes and an arch supporting foot orthoses may enhance selective activation of the muscle.
Effect of soft inflatable orthosis on the medial longitudinal arch in patients with flexible flatfoot deformity. Zhang Yi-Jun,Long Xiao,Du Jing-Yu,Liu Tao,Lin Xiang-Jin Clinical biomechanics (Bristol, Avon) BACKGROUND:Orthoses can stabilize the foot and restore the medial longitudinal arch for symptomatic flexible flatfoot. However, the effectiveness of orthoses remains controversial. The purpose of this study was to evaluate effectiveness of a customized soft inflatable orthosis on the medial longitudinal arch of flexible flatfoot patients under load. METHODS:We obtained CT scans of the feet of 14 healthy volunteers and 14 patients with flexible flatfoot under non- and simulated weight-bearing conditions. Then CT scans under the same conditions were taken for patients with flexible flatfoot equipped with soft inflatable orthosis. Three-dimensional models of the medial longitudinal arch and hindfoot were constructed from CT images. The three-dimensional mobility of the medial longitudinal arch joints under load was compared between patients with flexible flatfoot equipped with soft inflatable orthosis or not. FINDINGS:From non- to simulated weight-bearing condition, the eversion and dorsiflexion of the talocalcaneal joint, the eversion of the talonavicular joint, the abduction and dorsiflexion of the cuneonavicular joint, and the dorsiflexion of the first tarsometatarsal joint were significantly larger in patients with flexible flatfoot than healthy volunteers. The customized soft inflatable orthosis could reduce the eversion of the talonavicular joint and the eversion and dorsiflexion of the talocalcaneal joint. INTERPRETATION:The soft inflatable orthosis is effective to improve medial longitudinal arch height and reduce excessive mobility of joints for flexible flatfoot deformity. The results of this study could provide evidence for the optimal orthosis design to treat flexible flatfoot in the future. 10.1016/j.clinbiomech.2021.105418
Effect of foot shape on the three-dimensional position of foot bones. Ledoux William R,Rohr Eric S,Ching Randal P,Sangeorzan Bruce J Journal of orthopaedic research : official publication of the Orthopaedic Research Society To eliminate some of the ambiguity in describing foot shape, we developed three-dimensional (3D), objective measures of foot type based on computerized tomography (CT) scans. Feet were classified via clinical examination as pes cavus (high arch), neutrally aligned (normal arch), asymptomatic pes planus (flat arch with no pain), or symptomatic pes planus (flat arch with pain). We enrolled 10 subjects of each foot type; if both feet were of the same foot type, then each foot was scanned (n=65 total). Partial weightbearing (20% body weight) CT scans were performed. We generated embedded coordinate systems for each foot bone by assuming uniform density and calculating the inertial matrix. Cardan angles were used to describe five bone-to-bone relationships, resulting in 15 angular measurements. Significant differences were found among foot types for 12 of the angles. The angles were also used to develop a classification tree analysis, which determined the correct foot type for 64 of the 65 feet. Our measure provides insight into how foot bone architecture differs between foot types. The classification tree analysis demonstrated that objective measures can be used to discriminate between feet with high, normal, and low arches. 10.1002/jor.20262
Results of subtalar arthroereisis for posterior tibial tendon dysfunction stage IIA1. Based on 35 patients. Viladot Voegeli Antonio,Fontecilla Cornejo Nicolás,Serrá Sandoval Juan Andrés,Alvarez Goenaga Fernando,Viladot Pericé Ramón Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons BACKGROUND:The aim of the study was to evaluate the clinical and radiological results obtained in the treatment of adult flexible flatfoot secondary to posterior tibial dysfunction with subtalar arthroereisis using a Kalix endorthesis. METHODS:35 patients (37 feet) were studied, having been operated between January 2010 and January 2015 for reducible flatfoot secondary to posterior tibial tendon dysfunction stage IIA1 of Bluman. RESULTS:The average follow up was 47.52 months with a minimum of 14 months and a maximum of 75 months. The average age was 54.85, with an age range from 40 to 80 years old. In 74% of cases excellent or good results were obtained, according to our evaluation. The most common complication of this procedure was persistent pain in the sinus tarsi. 35% of cases in this group required implant removal for this reason. CONCLUSIONS:We believe that arthroereisis is valid for the treatment of flat foot secondary to posterior tibial tendon dysfunction at this stage, giving a high percentage of good and excellent results. 10.1016/j.fas.2016.10.006
Effect of plano-valgus foot posture on midfoot kinematics during barefoot walking in an adolescent population. Caravaggi Paolo,Sforza Chiarella,Leardini Alberto,Portinaro Nicola,Panou Artemisia Journal of foot and ankle research BACKGROUND:Plano-valgus is a common alteration of the paediatric foot, characterized by valgus hindfoot, foot pronation and drop of the medial longitudinal arch. Despite their importance in the diagnosis and classification of plano-valgus foot condition, little information is available on functional alterations of the major joints spanning the medial longitudinal arch - i.e. midtarsal and tarso-metatarsal. Aim of the study was to provide objective description of the alterations in plano-valgus midfoot joints with respect to those in an age-matched normally-developed feet population. METHODS:Twenty adolescents (13.3 ± 0.8 years) with bilateral plano-valgus feet underwent clinical examination and were gait-analysed via a validated 4-segment foot model. This allowed to measure static foot posture, kinematics of the main foot joints, and medial longitudinal arch deformation during walking at comfortable speed. Range of motion and temporal profiles of joint rotations were compared to those from a control population of age-matched adolescents with normally-developed feet. RESULTS:The plano-valgus midtarsal joint was more dorsiflexed, everted and abducted than that in the control group, and showed reduced sagittal-plane RoM (plano-valgus = 15.9 degrees; control = 22.2 degrees;  <  0.01). The tarso-metarsal joint was more plantarflexed and adducted, and showed larger frontal-plane RoM. The MLA showed larger RoM and was lower throughout the stance phase of the gait cycle. CONCLUSION:Significant postural and kinematic alterations are present at the midtarsal and tarso-metarsal joints of adolescents with plano-valgus feet. Objective identification and quantification of plano-valgus foot alterations, via non-invasive gait-analysis, is relevant to improving the diagnosis of this condition and to evaluating the effect of conservative treatments and of surgical corrections by different techniques. 10.1186/s13047-018-0297-7
Deformity and degeneration in the hindfoot and midfoot joints of the adult acquired flatfoot. Greisberg Justin,Hansen Sigvard T,Sangeorzan Bruce Foot & ankle international Adult acquired flatfoot is generally characterized by loss of the longitudinal arch, hindfoot valgus, and forefoot abduction, but the precise deformity has not been adequately described at the level of individual joints. Simulated weightbearing CT scans and plain radiographs of 37 symptomatic flat feet were examined in this study. The degree of arthritic degeneration was assessed in the major hindfoot and midfoot joints, and the location of deformity was studied along the medial column of the arch. Moderate to severe degeneration was seen in about one-third of talonavicular, subtalar, and calcaneocuboid joints. The medial column of the arch collapsed through the talonavicular joint in some feet, through the medial naviculocuneiform joint in others, but rarely through both. First tarsometatarsal joint subluxation was a frequent finding as well. In this small series, neither the degree of degenerative arthritis nor the amount of joint deformity was seen to correlate with patient age. Furthermore, no correlation was observed between foot deformity and joint degeneration. 10.1177/107110070302400704
The injury risk associated with pes planus in athletes. Michelson J D,Durant D M,McFarland E Foot & ankle international Despite the common prophylactic use of rigid orthotics in athletes with flat feet to prevent subsequent injury, there is little scientific data in the literature examining the relationship between pes planus and athletic injuries to the lower extremity. The current prospective study was undertaken to establish what relationship, if any, exists between foot morphology and subsequent lower extremity injury. A total of 196 subjects were enrolled in the study, of which 143 (73%) were male and 53 (27%) were female. Forty-two percent of the participants (83) engaged in contact sports. There were a total of 227 episodes of injury involving the lower extremity. Logistic regression using contact sports, gender, and all of the different foot contact areas that were measured at the beginning of the study was undertaken. Although gender and participation in contact sports was predictive of some lower extremity injuries, the existence of pes planus as measured by medial midfoot contact area as a percentage of total contact area was not a risk factor for any injury of the lower extremity. This study shows that in an athletic population that is representative of collegiate athletics, the existence of flat footedness does not predispose to subsequent lower extremity injury. The routine prophylactic use of orthotics in flat-footed athletes to prevent future injury may therefore not be justified based on the data available. 10.1177/107110070202300708
Effect of foot orthosis design on lower limb joint kinematics and kinetics during walking in flexible pes planovalgus: A systematic review and meta-analysis. Desmyttere Gauthier,Hajizadeh Maryam,Bleau Jacinte,Begon Mickael Clinical biomechanics (Bristol, Avon) BACKGROUND:Foot orthoses are commonly used for the management of excessive foot pronation in people with pes planovalgus. However, results are inconsistent due to variability in orthosis geometrical designs. This systematic review with meta-analysis aimed to classify and investigate the effects of foot orthoses, based on their design, in terms of lower limb kinematics and kinetics in people with pes planovalgus. METHODS:Electronic databases were searched up until August 2017. Peer-reviewed journal studies including adult participants with flexible pes planovalgus and reporting kinematics and kinetics effects of foot orthoses during walking were included and classified based on the orthosis design. Eleven studies were retained and assessed according to methodological (mean 76.1%; range [63.2%-84.2%] - high) and biomechanical (mean 71.6%; range [44.4%-100%] - moderate) qualities. Meta-analysis was performed by calculating the effect size, using standardized mean differences, between control and orthotics conditions. FINDINGS:Meta-analysis revealed less rearfoot eversion with the use of foot orthoses including medial forefoot or both forefoot and rearfoot posting. However, no significant effect of foot orthoses with arch support and neutral rearfoot posting to control excessive foot pronation were found. In terms of kinetics, none of the foot orthoses showed effects. INTERPRETATION:Using medial posting is the most effective foot orthotic feature to reduce the peak rearfoot eversion and to control excessive foot pronation. Nevertheless, heterogeneity between study protocols contributes to the low evidences of foot orthoses effects on kinematics and kinetics during walking in people with pes planovalgus. 10.1016/j.clinbiomech.2018.09.018
Percutaneous minimal invasive Achilles tendon lengthening improves clinical and radiographic outcomes in severe flexible flatfeet with shortened triceps sureae complex in early childhood: A retrospective study. Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons BACKGROUND:Severe flexible flatfeet with triceps surae complex shortening are prognostically unfavorable in early childhood and may compromise normal foot development. METHODS:This retrospective, IRB-approved study included 20 children (38 feet) under 6 years with severe flexible flatfeet and triceps surae complex shortening. Treatment included minimally invasive percutaneous achilles tendon lengthening followed by a 4-week cast fixation and corrective orthotic therapy under talo-navicular reposition for at least 6-months. Preoperative weightbearing x-rays and at the last available follow-up included anteroposterior talus-first metatarsal angle and lateral talus pitch, Meary's and talocalcaneal angle and were compared to reference values. ROM, surgeon-rated clinical outcomes and complications/re-interventions were evaluated. RESULTS:Age at surgery was 3.7 years (1.3-5.9 y) and follow-up time was 4.3 years (1.1-8.9 y). No complications occurred. Clinical outcome was good (68 %) to very good (26 %). Ratio of normal angles increased significantly for three angles. Dorsiflexion ROM improved from -5.0 ± 6.8° at baseline to 15.7 ± 7.6°. CONCLUSIONS:With significant improvements in clinical and radiographic outcomes, minimal-invasive percutaneous Achilles tendon lengthening followed by orthotic therapy seems to be a valuable treatment option for selected preschool-aged patients with severe, flexible flatfeet with significantly shortened triceps surae. LEVEL OF EVIDENCE:IV. 10.1016/j.fas.2022.12.009
Assessment of the Foot's Longitudinal Arch by Different Indicators and Their Correlation with the Foot Loading Paradigm in School-Aged Children: A Cross Sectional Study. Szczepanowska-Wołowiec Beata,Sztandera Paulina,Kotela Ireneusz,Zak Marek International journal of environmental research and public health BACKGROUND:There are numerous studies assessing the morphological structure of the foot, but there is a notable scarcity of those focused on juxtaposing various longitudinal arch indices with foot loading paradigm. The present study aimed to determine the overall reliability, diagnostic accuracy of respective variables, and their correlation with the foot loading paradigm. METHODS:The study group consisted of 336 children, aged 10-15 years (girls 49.1% and boys 50.9%). The morphological structure of the plantar part of the foot in static conditions was assessed with the aid of a 2D podoscan. Individual foot loading paradigm in static conditions was assessed making use of the FreeMed platform. RESULTS:Staheli (SI), Chippaux-Smirak (CSI), and Sztriter-Godunow (KY) indices were strongly correlated with each other (ρ > 0.84, < 0.001). Own research corroborated an increased pressure of hollow feet, as assessed by the SI, CSI, and KY indices, on the forefoot and the hindfoot, foot zones B, E, F; these correlations being statistically significant. The results yielded by the present study also indicate an increased pressure on the metatarsal, and foot zones C, D of the flat feet. CONCLUSIONS:Flatfootedness is not believed to be a common deformity among children and adolescents. The SI, CSI, and KY indices were found to be strongly correlated, as well as proved reliable in assessing the foot's longitudinal arch. 10.3390/ijerph18105196
Effect of foot orthoses on the medial longitudinal arch in children with flexible flatfoot deformity: A three-dimensional moment analysis. Jafarnezhadgero Amir Ali,Shad Morteza Madadi,Majlesi Mahdi Gait & posture Foot orthoses are often used to correct altered gait patterns. The purpose of this study was to investigate how foot orthoses can modify the magnitude of three dimensional moments of ankle, knee, and hip joints during a stride of gait in children with flexible flat feet. Bilateral gait data were collected from fourteen male children (age 10.2±1.4 years) suffering from flat feet syndrome. In order to obtain the kinematics data, a Vicon system with six cameras (100Hz) was used and two Kistler force plates (1000Hz) to record the kinetics data under each leg. Arc support foot orthoses were used as an intervention. Paired-sample T-test was used for within-group comparisons (α=0.05). The results of data analysis showed that foot orthoses can decrease the ankle evertor moment, knee and hip abductor moments and hip flexor moment in dominant lower limb. In non-dominant lower limb, using the orthoses can decrease evertor and internal rotator moments at the ankle, flexor and internal rotator moments at the knee and extensor moment at the hip, while it can increase dorsiflexor moment at the ankle. The findings imply that effects of orthoses on three dimensional moments differ in dominant and non-dominant lower limbs. Furthermore, results demonstrated that dominant and non-dominant lower limbs would also show different responses to the same intervention. 10.1016/j.gaitpost.2017.04.011
Cadaveric flatfoot model: ligament attenuation and Achilles tendon overpull. Blackman Andrew J,Blevins Joanna J,Sangeorzan Bruce J,Ledoux William R Journal of orthopaedic research : official publication of the Orthopaedic Research Society Flatfoot deformity is characterized by loss of the medial longitudinal arch, forefoot abduction, hindfoot eversion, and often Achilles tendon contracture. Our objectives were to validate a cadaveric flatfoot model that involves selective ligament attenuation and to determine if Achilles tendon overpull is associated with increased pes planus severity. We measured the three-dimensional (3D) orientation of the bones of interest in the unloaded, loaded, and Achilles tendon overpull conditions. A flatfoot model was created by attenuating ligaments involved in the pes planus deformity followed by cyclic axial loading, and bone orientations were acquired in the three conditions. Significant differences seen between normal feet and flat feet were consistent with those seen with the pes planus deformity. The first metatarsal dorsiflexed and abducted relative to the talus. The navicular abducted relative to the talus. The calcaneus everted relative to the tibia. The talus plantar flexed and adducted. Achilles overpull resulted in first metatarsal-to-talus dorsiflexion and navicular-to-talus abduction. Thus, selective ligament attenuation followed by cyclic axial loading can create a cadaveric flatfoot model consistent with the in vivo deformity. Longitudinal arch depression, hindfoot eversion, talonavicular joint abduction, forefoot abduction, and talar plantar flexion were seen. Simulated Achilles tendon contracture increased the severity of the deformity, particularly in arch depression and forefoot abduction. 10.1002/jor.20930
Clinical Outcomes of Fusion in Type II Accessory Naviculars With or Without Asymptomatic Flatfeet. Foot & ankle international BACKGROUND:Few studies have reported the clinical outcomes of fusion surgeries for type II accessory naviculars. Whether the combination of accessory naviculars and asymptomatic flatfoot will result in worse outcomes in accessory navicular surgeries remains to be elucidated. Our study aims to report the clinical outcomes of fusion for type II accessory naviculars and make a subgroup comparison among accessory navicular patients with or without asymptomatic flatfeet. METHODS:From May 2017 to June 2021, all painful type II accessory naviculars with or without asymptomatic flatfeet in our inpatient center were reviewed, and those who only underwent fusion surgeries were included in the retrospective study. Visual analog scale (VAS) scores, American Orthopaedic Foot & Ankle Society (AOFAS) midfoot scores, Tegner activity level scores, complications, patient-reported satisfaction, and imaging results (Meary angle in the weightbearing lateral view, talo-first metatarsal angle and talonavicular coverage angle in the weightbearing anteroposterior view) were used to describe outcomes. RESULTS:Thirty-two eligible patients responded to the latest follow-up request and were included in this study. The mean follow-up duration was 37.1 ± 16.0 months. The average VAS pain score improved from 4.7 ± 1.8 preoperatively to 0.9 ± 1.2 at the latest follow-up (<.001). The average AOFAS midfoot score improved from 67.1 ± 8.5 preoperatively to 90.2 ± 10.7 at the latest follow-up (<.001). The preoperative and postoperative Tegner activity level scores were similar (3.3 ± 1.5 vs 3.5 ± 1.6, =.136). The overall complication rate was 37.5%. The most common complication was nonunion (31.3%). The overall satisfaction rate was 90.6%. Similar outcomes were observed between the flatfoot and the nonflatfoot subgroups. CONCLUSION:Fusion for painful type II accessory naviculars resulted in good symptom relief, function improvement, and patient satisfaction at midterm follow-up, but the nonunion rate was relatively high. Fusion for painful type II accessory naviculars with or without asymptomatic mild to moderate flatfoot brought about similar clinical outcomes. LEVEL OF EVIDENCE:Level III, retrospective comparative study. 10.1177/10711007221140847
Validity of a simple footprint assessment board for diagnosing the severity of flatfoot: a prospective cohort study. BMC musculoskeletal disorders BACKGROUND:A simple, non-quantitative, and cost-effective diagnostic tool would enable the diagnosis of flatfoot without need for specialized training. A simple footprint assessment board that investigates which toe the cord passes through from the centre point of the heel to the most lateral point of the medial contour of the footprint has been developed to assess flatfoot. The purpose of this study was to verify the validity of a simple footprint assessment board for flatfoot. METHODS:Thirty-five consecutive patients with foot pain, foot injury, or any associated symptoms who underwent computed tomography (CT) were analysed prospectively. At the time of the CT scan, a footprint analysis using a simple footprint assessment board was performed. The navicular index, tibiocalcaneal angle, and calcaneal inclination angle were evaluated by CT to assess flat feet. These three criteria were compared to those evaluated with the simple footprint assessment board by regression analysis. In addition, the same analysis was conducted separately for young, middle-aged, and older patients in order to investigate each age group. RESULTS:The navicular index and tibiocalcaneal angle generally decreased as the score of the simple footprint assessment board increased. Calcaneal inclination angle generally increased as the score of the simple footprint assessment board increased. As the scores of the simple footprint assessment board decreased by approaching the great toe, the navicular index and tibiocalcaneal angle were higher and calcaneal inclination angle was lower, which is indicative of a higher likelihood of flatfoot. The scores derived from the simple footprint assessment board was correlated with these three criteria measured by CT, not only when the result of simple footprint assessment board was set as a non-continuous variable but also when the result was set as a continuous variable. The results of the age-stratified survey were similar for all groups. CONCLUSIONS:The findings of this study suggest that a simple footprint assessment board can be potentially useful to detect flatfoot. TRIAL REGISTRATION:Retrospectively registered. 10.1186/s12891-021-04154-3
Load response of the medial longitudinal arch in patients with flatfoot deformity: in vivo 3D study. Kido Masamitsu,Ikoma Kazuya,Imai Kan,Tokunaga Daisaku,Inoue Nozomu,Kubo Toshikazu Clinical biomechanics (Bristol, Avon) BACKGROUND:The acquisition of flatfoot by an adult is thought to primarily be caused by posterior tibial tendon dysfunction, although some other causes, such as congenital flexible flatfoot or an accessory navicular, may also be responsible. The objective of this study was to evaluate the bone rotation of each joint in the medial longitudinal arch (MLA) and compare the response in healthy feet with that in flat feet by analyzing the reconstructive three-dimensional (3D) CT image data during weightbearing. METHODS:CT scans of 20 healthy feet and 24 feet with flatfoot deformity were taken in non-load condition followed by full-body weightbearing condition. Images of the tibia and MLA bones (first metatarsal bone, cuneiforms, navicular, talus, and calcaneus) were reconstructed into 3D models. The volume merge method in three planes was used to calculate the bone-to-bone relative rotations. FINDINGS:Under loading conditions, the flatfoot dorsiflexed more in the first tarsometatarsal joint, and everted more in the talonavicular and talocalcaneal joints compared with the healthy foot. The total relative rotation was larger in the flatfoot compared with the healthy foot only in the first tarsometatarsal joint. INTERPRETATION:Supporting the MLA in the sagittal direction and the subtalar joint in the coronal direction may be useful for treating flatfoot deformity. The first tarsometatarsal joint may play an important role in diagnosing or treating flatfoot deformity. 10.1016/j.clinbiomech.2013.04.004
Lateral collapse of the tarsal navicular in patients with rheumatoid arthritis: Implications for pes planovarus deformity. Matsumoto Takumi,Maenohara Yuji,Chang Song Ho,Hirose Jun,Juji Takuo,Ito Katsumi,Tanaka Sakae Modern rheumatology OBJECTIVES:In patients with rheumatoid arthritis (RA), the talonavicular joint is commonly involved and midfoot collapse can lead to progressive flattening of the arch. Despite a general awareness of the important structural role of the talonavicular joint in rheumatoid foot disease, details of its destructive pattern have not been elucidated. METHODS:We cross-sectionally investigated 176 RA patients (342 feet) and classified their feet into the following five groups according to radiographic findings: arthritis (RA changes with normal navicular shape), Müller-Weiss Disease (MWD) (collapse of the lateral aspect of the tarsal navicular), flat (flattened navicular), ankylosis (ankylosis of the talonavicular joint), and normal. We compared medical histories and radiographic measurements among all five groups. RESULTS:The arthritis group comprised 91 feet, 36 in the MWD group, nine in the flat group, 12 in the ankylosis group, and 194 classified as normal. The MWD group demonstrated a trend towards pes planovarus deformity in contrast to pes planovalgus deformity in the arthritis group. Corticosteroid use and the mean daily dosage were the highest in the MWD group. CONCLUSIONS:This report revealed a high prevalence of MWD-like changes to the navicular in RA patients and its association with pes planovarus deformity and corticosteroid usage. 10.1080/14397595.2017.1416905
Proximal oblique-domed osteotomy of the first metatarsal for the treatment of hallux valgus associate with flat foot: effect to the correction of the longitudinal arch of the foot. Takao Masato,Komatsu Fumito,Oae Kazunori,Miyamoto Wataru,Uchio Yuji,Ochi Mitsuo,Matsushita Takashi Archives of orthopaedic and trauma surgery INTRODUCTION:Flat foot and/or metatarsal primus varus are the major causes of hallux valgus, and it is important to correct these deformities in order to prevent the recurrence of this condition. We demonstrate the clinical and radiological assessment of the correction of hallux valgus, metatarsal primus varus, and flat foot after proximal oblique-domed osteotomy of the metatarsus with distal soft tissue reconstruction. MATERIALS AND METHODS:Twenty-seven feet of 22 patients with moderate or severe hallux valgus who had undergone proximal oblique-domed osteotomy were studied. After the adductor hallucis tendon was cut at the attachment of the proximal phalanx and at the sesamoid bone, the osteotomy was performed 3 cm dorsal-distal to the metatarsocuneiform joint to transfer distal fragment approximately 5 mm in the plantar direction, and rotated laterally decreasing the first-second intermetatarsal angle to 5 degrees. RESULTS:The mean AOFAS score was 54.1 +/- 2.8 points at pre-operation and 92.8 +/- 4.8 points at the most recent follow-up (P < 0.0001). Significant improvement was seen between the hallux valgus angle (P < 0.0001), first-second intermetatarsal angle (P < 0.0001), first-fifth intermetatarsal angle (P < 0.0001), talar pitch (P = 0.0032), and calcaneal plantar angle (P = 0.0327) before surgery and at one year after surgery. The average improvement of the talar pitch and calcaneal plantar angle was 2.6 +/- 1.4 and 2.4 +/- 1.5 degrees, respectively. CONCLUSION:This study suggest that proximal oblique-domed osteotomy of the metatarsal as a surgical procedure for the treatment of moderate or severe hallux valgus with flat foot can be recommended to correct the longitudinal arch of the foot and the first-second intermetatarsal angle. 10.1007/s00402-007-0362-3
Cluster analysis to identify foot motion patterns in children with flexible flatfeet using gait analysis-A statistical approach to detect decompensated pathology? Böhm Harald,Oestreich Claudia,Rethwilm Roman,Federolf Peter,Döderlein Leonhard,Fujak Albert,Dussa Chakravarty U Gait & posture INTRODUCTION:The paediatric flexible flatfoot constitutes the major cause of clinic visits for orthopaedic foot problems. It shows variations of deformities in different planes and locations of the foot and its indication for treatment have been extensively discussed. Despite its high prevalence there exists no classification of flatfeet during walking as a prerequisite for treatment decision. Therefore, the aim of this study is to classify flexible flatfeet based on 3D foot kinematics during walking. METHODS:Patients age 7-17 years with flexible flatfeet (N = 129, 255 feet) of non-neurogenic or syndromic origin, were retrospectively included. Patients underwent gait analysis using the Oxford Foot Model after standard clinical examination. A k-means cluster analysis was performed on 3 scores derived from the principal component analysis of the foot kinematic waveforms over the gait cycle. Gait and clinical parameters were then statistically tested between clusters. RESULTS:Cluster analysis revealed two groups of flexible flatfeet that were discriminated best by the inversion at push-off during walking. Cluster 2, including 110 feet, showed an average eversion instead of an inversion at push-off and a lower number of heel rises in the clinical test. Both was significantly different between clusters (p < 0.001). DISCUSSION:Based on the findings, the resultant clusters can be interpreted as describing compensated and decompensated feet, with the latter presenting a group that may require surgical interventions, even if they are not yet present with pain. The hindfoot inversion capability at push-off is the most important variable in the 3D gait analysis to classify flexible flat feet. 10.1016/j.gaitpost.2019.04.028
The pictogram of the pes planus from the first century AD. Wokaunn Mario,Ferenčić Stella Fatović-,Mikolaučić Michele International orthopaedics PURPOSE:This study presents a pictogram engraved into the Marble Road of the ancient town of Ephesus, with a special emphasis on one part of it which represents a flat foot. Although the flat foot is a widespread and common disturbance in all time periods, we were motivated by a lack of its representation within iconographical, historical or other sources. METHOD:Aiming to confirm the diagnosis objectively we applied the modern diagnostic methodology, arch index (AI). The result was 0.33, which is a mathematical proof that the Ephesus foot is definitely flat. CONCLUSION:To the best of our knowledge, this picture from the first century AD is among the oldest representations of a flat foot in history. 10.1007/s00264-013-2020-4
Automatic Detection of Calcaneal-Fifth Metatarsal Angle Using Radiograph: A Computer-Aided Diagnosis of Flat Foot for Military New Recruits in Taiwan. Yang Chin-Hua,Chou Kuei-Ting,Chung Mu-Bai,Chuang K S,Huang Tzung-Chi PloS one Flatfoot (pes planus) is one of the most important physical examination items for military new recruits in Taiwan. Currently, the diagnosis of flatfoot is mainly based on radiographic examination of the calcaneal-fifth metatarsal (CA-MT5) angle, also known as the arch angle. However, manual measurement of the arch angle is time-consuming and often inconsistent between different examiners. In this study, seventy male military new recruits were studied. Lateral radiographic images of their right and left feet were obtained, and mutual information (MI) registration was used to automatically calculate the arch angle. Images of two critical bones, the calcaneus and the fifth metatarsal bone, were isolated from the lateral radiographs to form reference images, and were then compared with template images to calculate the arch angle. The result of this computer-calculated arch angle was compared with manual measurement results from two radiologists, which showed that our automatic arch angle measurement method had a high consistency. In addition, this method had a high accuracy of 97% and 96% as compared with the measurements of radiologists A and B, respectively. The findings indicated that our MI registration measurement method cannot only accurately measure the CA-MT5 angle, but also saves time and reduces human error. This method can increase the consistency of arch angle measurement and has potential clinical application for the diagnosis of flatfoot. 10.1371/journal.pone.0131387
Alterations in talar morphology associated with adult flatfoot. Anderson J G,Harrington R,Ching R P,Tencer A,Sangeorzan B J Foot & ankle international To gain a better understanding on the anatomy of the factors contributing to symptomatic flatfoot, we compared the shape of the talus in feet that were flat to that in control tali from feet with a normal arch. Computed tomographic (CT) scans were performed on 9 adult patients with 10 symptomatic flatfoot deformities. CT scans of 10 feet being evaluated for acute trauma not involving the talus were randomly selected as controls. Flatfoot tali tended to be of greater overall length than the control tali, and this difference was not statistically significant. Statistically significant differences were found when comparing ratios of talar length with talar width (P = 0.011), talar length with talar height (P = 0.001) (they were long relative to their height and width), and head length with head width (P = 0.001) for individual tali from the two groups. The tali from the flatfoot group were narrower in width and shorter in height when compared with overall length and had heads that were more elongated in the transverse plane than tali in feet with a normal appearance. CLINICAL CORRELATION: When performing surgical correction of a flatfoot in an adult, appearance of the foot rather than standard radiographic parameters should be used to judge the reduction. The altered shape of the bone may alter the standard radiographic parameters. 10.1177/107110079701801105
Effectiveness of subtalar arthroereisis with endorthesis for pediatric flexible flat foot: a retrospective cross-sectional study with final follow up at skeletal maturity. Indino Cristian,Villafañe Jorge Hugo,D'Ambrosi Riccardo,Manzi Luigi,Maccario Camilla,Berjano Pedro,Usuelli Federico Giuseppe Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons BACKGROUND:Pediatric flexible flatfoot is sometimes asymptomatic but it can rarely cause physical impairment, pain, and difficulty walking. We evaluated the radiographic effectiveness of intervention of subtalar arthroereisis with endorthesis for pediatric flexible flatfoot with final follow-up at skeletal maturity. METHODS:This is a retrospective cross-sectional study. 56 consecutive patients (112 feet) who underwent surgical treatment with subtalar arthroereisis for pediatric flexible flatfoot (mean age at final follow-up 15.5±1.2 years, 39.3% female) were enrolled. All the radiographic studies were performed in the hospital. Radiographs (standard weight-bearing radiographs of the foot with anteroposterior and lateral view) were used to measure lateral talocalcaneal angle (LTC), calcaneal pitch angle (CP), Meary's angle (MA), anteroposterior talonavicular angle (APTN), talonavicular uncoverage percent (TNU). Minimum follow-up was 18 months. Measures were assessed pre-operatively and at the final follow-up. Clinical and functional parameters were assessed at the final follow-up. RESULTS:Children who underwent surgical treatment with subtalar arthroereisis for pediatric flexible flatfoot exhibited a statistically significant improvement in all radiographic measurement parameters at the last follow-up at skeletal maturity (all, p<0.004). Mean follow-up was 40.1±23.6months. Clinical parameters were not correlated with the foot radiographic parameters at follow up period. CONCLUSIONS:Our results suggest that endorthesis in pediatric flexible flatfoot was effective for improving radiographic parameters at skeletal maturity. The amount of the morphologic correction at the end of the skeletal growth should be expected mainly for lateral tarso-metatarsal alignment and talo-navicular congruency (MA, APTN, TNU). LEVEL OF EVIDENCE:Level III, retrospective study. 10.1016/j.fas.2018.12.002
Relationship of Body Mass Index and Footprint Morphology to the Actual Height of the Medial Longitudinal Arch of the Foot. Rosende-Bautista Carolina,Munuera-Martínez Pedro V,Seoane-Pillado Teresa,Reina-Bueno María,Alonso-Tajes Francisco,Pérez-García Sergio,Domínguez-Maldonado Gabriel International journal of environmental research and public health The medial longitudinal arch height of the foot is linked to individual characteristics such as sex and body mass index, and these characteristics have been shown to be associated with conditions such as flat feet. In this cross-sectional descriptive study, we examined the medial longitudinal arch morphology in an adult population to determine if there are differences related to sex and body mass index, and values were obtained for the foot posture index. Normalized anthropometric measurements and arch indices were calculated from footprints. Groups, defined by sex and body mass index, were compared, and the correlations between body mass index and the variables were determined. In the population studied (266 women and 177 men), significant differences between men and women for the foot posture index and normalized arch measurements were found. Analysis of the variables related to body mass index indicated there were significant differences in arch indices. Significant differences and positive correlations were also found between the arch index and body mass index for the left and right feet among the men and women studied. The results obtained allow us to reflect on and analyze whether the medial longitudinal arch morphology classification methods used in the clinical and research setting are adequate or whether the influence of factors such as body mass index can generate confusion. 10.3390/ijerph18189815
Weightbearing CT scan of severe flexible pes planus deformities. Ferri Melanie,Scharfenberger Angela V,Goplen Gord,Daniels Timothy R,Pearce Dawn Foot & ankle international BACKGROUND:The three-dimensional relationships of the bones in the foot in a flatfoot deformity are difficult to assess with standard radiographs. CT scans demonstrate these relationships but are typically made in a nonweightbearing mode. Our objective was to assess the use of a weightbearing CT apparatus to image the feet in patients with severe flexible pes planus deformities and to better define the anatomical changes that occur. MATERIALS AND METHODS:A specialized device was designed and constructed to simulate weightbearing to the feet during CT examination. Eighteen normal feet and 30 painful severe and flexible pes planus feet were imaged in both the non weightbearing and weightbearing states, set at 50% of body weight. Several measurements of intertarsal relationships were made of the pes planus and normal feet. Navicular floor to skin distance, forefoot arch angle, and subtalar joint subluxation were measured in the coronal plane in both the weightbearing and nonweightbearing states. T-tests were used to analyze measurements of navicular floor to skin distance and forefoot arch angle. RESULTS:The weightbearing device had a significant effect on foot configuration for both normal and pes planus feet (p = 0.0008) and (p < 0.0001) respectively for both floor to skin distance and forefoot arch angle. There was a significant difference between normal feet and pes planus feet with regard to the forefoot arch angle in the nonweightbearing (p = 0.02) and weightbearing states (p = 0.01). Four of the pes planus patients had evidence of subtalar joint subluxation which was more pronounced in the weightbearing state. There was no significant difference between the navicular floor to skin distance in the normal versus pes planus feet in either the non weightbearing (p = 0.05) or the weightbearing states (p = 0.07). CONCLUSION:A device was designed and constructed to apply a weightbearing load equal to that of 50% body weight with minimal to no patient discomfort. The resultant effects on foot configuration were significant, and are useful for assessment of degree of flexible flat foot deformity, thus guiding clinical management. The measure which most significantly differed between pes planus patients and normal volunteers was the forefoot arch angle. Forefoot arch angle may therefore be the most useful measure for the imaging diagnosis of flexible pes planus, and the degree of planus deformity. 10.3113/FAI.2008.0199
One- and multi-segment foot models lead to opposite results on ankle joint kinematics during gait: Implications for clinical assessment. Pothrat Claude,Authier Guillaume,Viehweger Elke,Berton Eric,Rao Guillaume Clinical biomechanics (Bristol, Avon) BACKGROUND:Biomechanical models representing the foot as a single rigid segment are commonly used in clinical or sport evaluations. However, neglecting internal foot movements could lead to significant inaccuracies on ankle joint kinematics. The present study proposed an assessment of 3D ankle kinematic outputs using two distinct biomechanical models and their application in the clinical flat foot case. METHODS:Results of the Plug in Gait (one segment foot model) and the Oxford Foot Model (multisegment foot model) were compared for normal children (9 participants) and flat feet children (9 participants). Repeated measures of Analysis of Variance have been performed to assess the Foot model and Group effects on ankle joint kinematics. FINDINGS:Significant differences were observed between the two models for each group all along the gait cycle. In particular for the flat feet group, opposite results between the Oxford Foot Model and the Plug in Gait were revealed at heelstrike, with the Plug in Gait showing a 4.7° ankle dorsal flexion and 2.7° varus where the Oxford Foot Model showed a 4.8° ankle plantar flexion and 1.6° valgus. INTERPRETATION:Ankle joint kinematics of the flat feet group was more affected by foot modeling than normal group. Foot modeling appeared to have a strong influence on resulting ankle kinematics. Moreover, our findings showed that this influence could vary depending on the population. Studies involving ankle joint kinematic assessment should take foot modeling with caution. 10.1016/j.clinbiomech.2015.03.004
The effects of foot orthosis and low-dye tape on lower limb joint angles and moments during running in individuals with pes planus. Gait & posture BACKGROUND:Pes Planus or Flat feet is one of the most common lower limb abnormalities. When runners with this abnormality participate in recreational running, interventional therapies could help in pain alleviation and enhance performance. To determine the most effective treatment, however, a biomechanical examination of the effects of each treatment modality is required. RESEARCH QUESTION:The aim of the present study was to investigate the effects of Foot Orthoses (FOs) and Low-Dye Tape (LDT) on lower limb joint angles and moments during running in individuals with pes planus. METHODS:kinematic and kinetic data of 20 young people with pes planus were measured during running in three conditions: (1) SHOD (2) with shoes and FOs (3) with shoes and LDT. One-way repeated measure ANOVA was used to investigate the impacts of the FOs and LDT on the lower limb joint angles and moments throughout the stance phase of the running cycle. RESULTS:The results showed that FOs reduced ankle eversion compared to SHOD and LDT (P < 0.001) and decreased the dorsiflexion angle (P = 0.005) and the plantarflexor moment compared to the SHOD (P < 0.001). FOs increased knee adduction angle (P = 0.021) and knee external rotator moment (P < 0.001) compared to both conditions and increased knee extensor and abductor moments compared to SHOD (P < 0.001). At the hip joint, FOs only increased hip external rotation compared with the LDT condition (P = 0.031); and LDT increased hip extensor moment compared to SHOD and FOs (P = 0.037) and also increased hip adduction angle compared to SHOD (P = 0.037). SIGNIFICANCE:FOs with a medial wedge appears to increase the external knee adduction moment and knee adduction angles, which are risk factors for the development and progression of knee osteoarthritis. Further, usage of FOs seems to reduce the ankle joint role in propulsion as it impacts the ankle sagittal angles and moments. 10.1016/j.gaitpost.2022.05.024
Consistency of visual assessments of arch height among clinicians. Cowan D N,Robinson J R,Jones B H,Polly D W,Berrey B H Foot & ankle international Flat feet and high-arched feet have been cited as risk factors for musculoskeletal injury and functional problems among runners and other active individuals, although there are no established quantitative definitions or measures for assessing either condition. As part of a larger study, four-plane photographs were made of the weight-bearing right foot of 246 young male Army trainees. These photographs were independently evaluated by six clinicians and rated on a scale of clearly flat-footed (category 1) to clearly high arched (category 5). There was much interclinician variability in the assessments, even for extremes of foot type. The probability of a clinician assessing a foot as clearly flat, given that another clinician had rated the foot as clearly flat, ranged from 0.32 to 0.79, with a median probability of 0.57, while for clearly high-arched feet, probabilities ranged from 0.0 to 1.00, with a median of 0.17. These findings demonstrate the need for objective standards and quantitative methods of evaluating foot morphology. 10.1177/107110079401500411
Shod wear and foot alignment in clinical gait analysis. Louey Melissa Gar Yee,Sangeux Morgan Gait & posture Sagittal plane alignment of the foot presents challenges when the subject wears shoes during gait analysis. Typically, visual alignment is performed by positioning two markers, the heel and toe markers, aligned with the foot within the shoe. Alternatively, software alignment is possible when the sole of the shoe lies parallel to the ground, and the change in the shoe's sole thickness is measured and entered as a parameter. The aim of this technical note was to evaluate the accuracy of visual and software foot alignment during shod gait analysis. We calculated the static standing ankle angles of 8 participants (mean age: 8.7 years, SD: 2.9 years) wearing bilateral solid ankle foot orthoses (BSAFOs) with and without shoes using the visual and software alignment methods. All participants were able to stand with flat feet in both static trials and the ankle angles obtained in BSAFOs without shoes was considered the reference. We showed that the current implementation of software alignment introduces a bias towards more ankle dorsiflexion, mean=3°, SD=3.4°, p=0.006, and proposed an adjusted software alignment method. We found no statistical differences using visual alignment and adjusted software alignment between the shoe and shoeless conditions, p=0.19 for both. Visual alignment or adjusted software alignment are advised to represent foot alignment accurately. 10.1016/j.gaitpost.2016.06.032
Is there a correlation between static radiographs and dynamic foot function in pediatric foot deformities? Böhm Harald,Döderlein Leonhard,Fujak Albert,Dussa Chakravarty U Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons BACKGROUND:Idiopathic flexible flatfeet, congenital clubfeet and pes cavovarus are the most common foot deformities in children. Accurate assessment to quantify the severity of these deformities by clinical examination alone can be challenging. Radiographs are a valuable adjunct for accurate diagnosis and effective treatment. However, static radiographs during relaxed standing may not reflect the dynamic changes in the foot skeleton during functional activities such as walking. Therefore, the aim of this study is to predict dynamic foot movements during walking from planar standing radiographs to reveal the significance of the radiographic analysis for the assessment of foot function. METHODS:Patients 8-17 years with flexible flatfeet (FFF, n=217) recurrent clubfeet (RCF n=38) and overcorrected clubfeet (OCCF, n=71) of non-neurogenic or syndromic origin and pes cavovarus due to peripheral neuropathy (PNP, n=48) were retrospectively included. Patients underwent gait analysis with the Oxford Foot Model and radiographic examination in anterior-posterior and lateral view during standing. Multilinear predictor analysis of selected gait parameters was performed based on radiographic measures. RESULTS:The variance that was explained by radiography was greatest for the transverse plane forefoot abduction with 33% for OCCF, 50% for RCF and 59% for PNP. Flatfeet and foot kinematics in the other planes or between rearfoot and tibia showed little or no relation. CONCLUSIONS:The static measures of foot deformities by radiography could explain only a small amount of variance in foot kinematics during walking, in particular for FFF. An explanation may be that the forces during weight bearing bear little resemblance to those during gait in terms of neither magnitude nor direction. These findings suggest that foot function cannot be accurately assessed solely from static radiographic observations of the foot, commonly undertaken in clinical practice. 10.1016/j.fas.2019.10.006
Double calcaneal osteotomy and percutaneous tenoplasty for adequate arch restoration in adult flexible flat foot. Basioni Yehia,El-Ganainy Abdel-Rahman,El-Hawary Ahmed International orthopaedics Treatment of adult acquired flexible flat foot deformity can be problematic. Triple arthrodesis for structural correction has been the standard of care, thus sacrificing hind foot motion. The objective of this study was to assess the value of double calcaneal osteotomies in improving structural alignment while maintaining hind foot motion, which may further protect the function of adjacent motion segments. Double calcaneal osteotomies (Evans osteotomy and posterior calcaneal displacement osteotomy) were performed on 17 feet of 14 patients. Postoperative follow-up showed significant improvement in clinical foot and ankle scores. 10.1007/s00264-010-1071-z
Rigid flatfoot. Jayakumar S,Cowell H R Clinical orthopaedics and related research The proper management of the rigid flat-foot requires an accurate diagnosis since the condition is treated on causal or rational basis. Calcaneonavicular coalition best seen on an oblique view of the foot may be treated by resection of the coalition with extensor digitorum brevis interposition. If the diagnosis is made sufficiently early, the resection can lead to an essentially normal foot. Coalition between the talus and the calcaneus may occur in the posterior, middle or anterior facet. The most common coalitions are seen in the middle facet area followed by those in the anterior facet with the posterior facet coalition rarely being seen. Coalitions in the area of the middle facet are usually managed nonoperatively; triple arthrodesis is used only if symptoms are not relieved by nonoperative measures. Resection of a talocalcaneal coalition in the middle facet is rarely indicated but occasionally will give relief when the coalition either presses on the medial plantar nerve or causes a mechanical disturbance of the ankle. Anterior facet coalitions should receive a trial of cast immobilization but frequently require triple arthrodesis. Other conditions such as rheumatoid and post-traumatic arthritis will frequently respond to a period of immobilization in a plaster cast. Triple arthrodesis has not been required in rheumatoid arthritis in the author's series but occasionally is necessary in the post-traumatic rigid flatfoot. Other rare causes of the rigid flatfoot should be kept in mind for a complete diagnostic evaluation since even a neoplasm (fibrosarcoma) has been reported to cause this symptom complex.
Is the foot structure of preschool children moderated by gender? Mickle Karen J,Steele Julie R,Munro Bridget J Journal of pediatric orthopedics OBJECTIVE:Although boys are frequently reported to have flatter feet than girls, there has been little systematic research to confirm or explain this structural difference between the genders. The objective of this study was to determine whether flat-footedness was moderated by gender in Australian preschool children and, if so, to determine the cause of this between-gender difference in structure of the plantar surface of the foot. METHODS:Foot anthropometry, Arch Index derived from plantar footprints, and midfoot plantar fat pad thickness measured by ultrasound were obtained for the left and right feet of 52 girls and 36 boys (mean age, 4.2 +/- 0.6 years). The children were recruited from 10 randomly selected preschools from the Illawarra region of New South Wales, Australia. RESULTS:In agreement with previous research, the preschool boys displayed significantly flatter feet than the girls (P < or = 0.04). Although there were no between-gender differences in structural foot dimensions, the boys had a significantly thicker midfoot fat pad than the girls by approximately 0.4 and 0.5 mm on both the right and left feet, respectively. CONCLUSIONS:The increased incidence of flat-footedness in boys compared with girls of the same age seems to be caused by a thicker plantar fat pad in the medial midfoot in boys. This suggests that the development of the medial longitudinal arch may be progressing at a slower rate in boys than in girls, and that intervention for a flexible flat foot, particularly for young boys, may be unnecessary. 10.1097/BPO.0b013e318173f782
Does the long-term use of medial arch support insole induce the radiographic structural changes for pediatric flexible flat foot? - A prospective comparative study. Choi Jun Young,Lee Dong Joo,Kim Seung Joo,Suh Jin Soo Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons BACKGROUND:Several conservative treatment methods, from intrinsic muscle exercises to orthoses, including insoles or specially designed shoes, have been introduced for pediatric flexible flat foot (PFFF). However, the structural effects of a long-term use of medial arch support insole remain unclear because the normal physiological maturation of the medial longitudinal arch cannot be ruled out. METHODS:From January 2005 to June 2015, 18 patients (34 feet) in group 1 (continuously insole applied group) and 13 patients (26 feet) in group 2 (untreated group) were enrolled. Medial arch support insole was applied from the age 10-11years to radiographic physeal closure. RESULTS:In group 1, talonavicular coverage angle, lateral talo-1st metatarsal angle, calcaneal pitch angle and medial cuneiform height were significantly changed at final follow-up, although all values were still within the abnormal range. Further, no significant differences were found in any of the increments of the radiographic parameters between group 1 and 2. CONCLUSIONS:Radiographic improvements were found in both of medial arch support insole treated or untreated group despite all radiographic values were still within the abnormal range. It was meaningful that the PFFF could be improved somewhat until the physes were closed. And the hindfoot alignment remained unchanged regardless of medial arch support insole application. 10.1016/j.fas.2019.05.017
Acquired flatfoot in adults due to dysfunction of the posterior tibial tendon. Pomeroy G C,Pike R H,Beals T C,Manoli A The Journal of bone and joint surgery. American volume 10.2106/00004623-199908000-00014
Current topic review: subtalar arthroereisis for the correction of flexible flatfoot. Needleman Richard L Foot & ankle international 10.1177/107110070502600411
The role of calcaneal osteotomies for correction of adult flatfoot. Trnka H J,Easley M E,Myerson M S Clinical orthopaedics and related research The surgical treatment of flatfoot deformity has evolved during the past three decades. Soft tissue procedures alone fail to reestablish anatomic bony alignment, and bony procedures alone fail to provide dynamic support to the arch. The goal of any procedure is to reestablish the inherently stable bony configuration with adequate soft tissue balance (tendon transfer) to maintain stability in the dynamic situation. Therefore, a combination of procedures, such as soft tissue procedures combined with calcaneal displacement osteotomies and/or lateral column lengthening, may provide optimal results. The focus of this review is the role of bony correction in the treatment of the adult acquired flatfoot deformity. 10.1097/00003086-199908000-00007
Bilateral peroneal spastic flat feet associated with congenital fusion of the navicular and talus. A case report. SANGHI J K,ROBY H R The Journal of bone and joint surgery. American volume
The distributed plantar vertical force of neutrally aligned and pes planus feet. Ledoux William R,Hillstrom Howard J Gait & posture The distributed vertical ground reaction forces were determined for a normative population and contrasted with data from subjects with flat feet. Nineteen asymptomatic subjects, 11 with a neutrally aligned foot type (normal arch) and 8 with a pes planus foot type (low arch), were studied as they walked barefoot across a pressure plate. The pressure plate data were converted to force values at seven locations (subhallucal, five submetatarsal and subcalcaneal) on the plantar aspect of the foot. The distributed loading pattern of the plantar soft tissue throughout the stance phase of gait was determined. Pes planus feet had significantly more force at the subhallucal area with no difference seen under the other areas. These data are indicative of aberrant first ray mechanics in pes planus feet. 10.1016/s0966-6362(01)00165-5
Utility outcome assessment of pes planus deformity. Aldebeyan Sultan,Sinno Hani,Alotaibi Mohammed,Makhdom Asim M,Hamdy Reggie C Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons BACKGROUND:Despite being a common condition, there are no objective measures in the literature to reflect the burden of pes planus on affected individuals. Our primary objective was to evaluate this burden by recruiting a sample from the general population using validated utility outcome measures. METHODS:Participants were recruited online and filled a questionnaire to help measure the health burden of pes planus. Three recognized utility outcome scores were used to compare the health burden of monocular blindness, binocular blindness, and pes planus. These included the standard gamble (SG), time trade-off (TTO), and visual analogue score (VAS). Paired t test, independent t test, and linear regression were used for statistical analysis. RESULTS:Ninety-two participants were included in the final analysis. The utility outcome scores (VAS, TTO, SG) for pes planus were 73±17, 0.90±0.08, and 0.88±0.12, respectively. The linear regression analysis showed that age was inversely proportional to the time trade-off. However, race, educational level, and income were not significant predictors of utility outcome score for pes planus. CONCLUSIONS:This study shows that the perceived burden of living with pes planus is comparable to living with some debilitating conditions. Our participants were willing to sacrifice 3.6 years of life, and have a procedure with a theoretical 12% mortality risk to attain perfect health. 10.1016/j.fas.2016.12.005
The classic: a study of the weak foot, with reference to its causes, its diagnosis, and its cure; with an analysis of a thousand cases of so-called flat-foot. 1896. Whitman Royal Clinical orthopaedics and related research 10.1007/s11999-009-1130-1
Acceleration of the calcaneus at heel strike in neutrally aligned and pes planus feet. Ledoux W R,Hillstrom H J Clinical biomechanics (Bristol, Avon) OBJECTIVE:The purpose of this research was twofold: (1) to study the impulsive acceleration of the calcaneus at heel strike in subjects with neutrally aligned (i.e., normal) feet and (2) to explore how the acceleration may differ in subjects with pes planus (i.e., flat) feet. The component of the acceleration vector aligned with the long axis of the tibia was quantified. DESIGN:Subjects with either foot type were instrumented and calcaneal acceleration was quantified during comfortable cadence locomotion. BACKGROUND:Aberrant peak acceleration has been associated with osteoarthritis. While tibial acceleration has been quantified, calcaneal acceleration has not. Additionally, foot morphology, or foot type, has demonstrated an effect on foot function and thus there may be differences in calcaneal acceleration between foot types. METHODS:Six subjects with neutrally aligned feet and six with pes planus feet were selected via a clinical exam. Accelerometers were attached to the posterior aspect of the medial surface of the calcanei bilaterally and 10 walking trials were collected.Results. The average baseline-to-peak acceleration for the neutrally aligned and pes planus feet was 4.79 g (SD, 2.14 g) and 5.24 g (SD, 3.28 g), respectively; the peak-to-peak acceleration was 5.03 g (SD, 2.74 g) and 6.75 g (SD, 3.89 g). There were no significant differences (P>0.05) between foot types. CONCLUSIONS:The calcaneal acceleration at heel strike for neutrally aligned and pes planus feet was not sensitive to foot type. RELEVANCE:Aberrant acceleration has been associated with the development of osteoarthritis [J. Biomech. 5 (3) (1972) 267; J. Biomech. 6 (1) (1973) 51; J. Biomech. 15 (7) (1982) 487]. Osteoarthritis at the subtalar joint, as well as the ankle and midtarsal joints, may be initiated and/or perpetuated by excessive calcaneal acceleration at heel strike. 10.1016/s0268-0033(01)00041-9
The relationship between quality of life and foot function in children with flexible flatfeet. Kothari A,Dixon P C,Stebbins J,Zavatsky A B,Theologis T Gait & posture Flat feet in children are common, and at times symptomatic, but the relationship between function and symptoms or impairment is still unclear. We undertook a prospective, observational study comparing children with paediatric flexible flat foot (PFF) and children with neutral feet (NF) using three dimensional gait analysis (3DGA). It was hypothesised that children with PFF would demonstrate differences in both spatio-temporal parameters of gait and foot and ankle kinematics compared to the NF group and that these differences would correlate with impaired quality of life (QoL). The kinematic differences were expected to be most marked in hindfoot coronal plane motion and forefoot sagittal and transverse plane motion. Eighty-three children between the ages of 8 and 15 were recruited in this study: Forty-two were classified as having PFF and forty-one as NF. Each child underwent 3DGA and completed the Oxford Ankle Foot Questionnaire for Children (OxAFQ_C). Reduced OxAFQ_C physical domain scores in the PFF children were associated with slower walking speed (p=0.014) and reduced normalised stride length (p=0.008). PFF children also demonstrated significantly increased hindfoot eversion and forefoot supination during gait. Significant differences between groups were not observed for other foot and ankle joint motions. Increased maximum hindfoot eversion and increased forefoot supination correlated strongly with lower QoL scores in PFF children. These data further our understanding of the functional characteristics that lead to impaired QoL in PFF children. These findings will help guide the surveillance and management of children with this ubiquitous condition. 10.1016/j.gaitpost.2015.02.012
Surgical strategies: use of the cuboid osteotomy in combination with the triple arthrodesis with lateral column overload. Haddad Steven L Foot & ankle international 10.3113/FAI.2009.0904
Addressing the Data Acquisition Paradigm in the Early Detection of Pediatric Foot Deformities. Rosero-Montalvo Paul D,Fuentes-Hernández Edison A,Morocho-Cayamcela Manuel E,Sierra-Martínez Luz M,Peluffo-Ordóñez Diego H Sensors (Basel, Switzerland) The analysis of plantar pressure through podometry has allowed analyzing and detecting different types of disorders and treatments in child patients. Early detection of an inadequate distribution of the patient's weight can prevent serious injuries to the knees and lower spine. In this paper, an embedded system capable of detecting the presence of normal, flat, or arched footprints using resistive pressure sensors was proposed. For this purpose, both hardware- and software-related criteria were studied for an improved data acquisition through signal coupling and filtering processes. Subsequently, learning algorithms allowed us to estimate the type of footprint biomechanics in preschool and school children volunteers. As a result, the proposed algorithm achieved an overall classification accuracy of 97.2%. A flat feet share of 60% was encountered in a sample of 1000 preschool children. Similarly, flat feet were observed in 52% of a sample of 600 school children. 10.3390/s21134422
Painful idiopathic rigid flatfoot in children and adolescents. Luhmann S J,Rich M M,Schoenecker P L Foot & ankle international Nine patients (13 feet) were identified whose primary complaints were of atraumatic-onset, chronic pain in the hindfoot exacerbated with increased activity and who had the diagnosis of idiopathic rigid flatfeet. Eight of 11 were greater than the 95th percentile in weight for their age. Exam under anesthesia showed moderate to significant improvement in hindfoot motion in 9 feet; 4 feet required fractional peroneal lengthenings. Only 5 of 11 patients have had sustained relief of pain and report unlimited activity level. Children and adolescents with painful idiopathic rigid flatfeet without known causation can have significant, persistent, disability and do not uniformly respond well to traditionally-described nonoperative Interventions. 10.1177/107110070002100111
Anatomical Study of Sinus Tarsi-Based Lateral Lengthening Calcaneal Osteotomy. Foot & ankle international BACKGROUND:Lateral lengthening calcaneal osteotomy (LL-CO) is commonly performed as a treatment for an abducted midfoot in pes planovalgus deformity. The purpose of this study is to investigate potential damage to medial structures with a sinus tarsi LL-CO. METHODS:Sixteen cadaver feet were used. Eight feet had an extended lateral approach, and 8 had a limited lateral (sinus tarsi) approach. All underwent a sinus tarsi LL-CO. Specimens were then dissected to identify inadvertent injury to medial structures. RESULTS:Sinus tarsi LL-CO was associated with damage to the sustentaculum tali and medial articular facets in 56% and 62.5% of specimens, respectively. No anterior or posterior facet injuries were found, although 56% of specimens had a confluent medial and anterior facet. CONCLUSION:Damage to the medial articular facet and sustentaculum is possible with a flat cut sinus tarsi LL-CO due to the curved nature of the relevant sinus tarsi and canal anatomy. CLINICAL RELEVANCE:Sinus tarsi LL-CO needs to be performed with caution since damage to the subtalar joint is possible. LEVEL OF EVIDENCE:Level II, prospective cohort study. 10.1177/10711007211041345
The typically developing pediatric foot - The data of the 1744 children in China. Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons BACKGROUND:The medial longitudinal arch (MLA) improves with age in childhood. However, it still causes parents to worry that children have flat feet. Due to the lack of a standard to quantitatively assess the arch development in kids at certain age, the pediatricians judge the flat feet by experience, causing many cases to be overtreated. The aim of this study was to plot the distribution of MLA parameters in children. METHODS:Children without lower limb deformity and lower limb pain were recruited from 12 primary schools and kindergartens in Chongqing province-level city. Foot length (FL) and navicular height (NH) was measured manually, arch index (AI) and arch volume (AV) were measured with the Foot Plantar Scanner. Each parameter was measured in both weight-bearing and non-weight-bearing positions. Significant differences were also compared between the measurements of consecutive years. RESULTS:This study was the first to use a three-dimensional laser surface scanner to measure the MLA parameters of children aged 3-12 years in China. 1744 children (871 girls, 873 boys) participated in this study. FL, NH, AI and AV varied significantly with age in both the weight-bearing and non-weight-bearing positions. These parameters have significant differences between the weighted and non-weighted positions (p < 0.05). CONCLUSIONS:The age distribution characteristics of these parameters indicated that the MLA improves with age. The establishment of a developmental scale for the children's MLA is necessary. 10.1016/j.fas.2021.04.005
Talocalcaneal coalition combined with flatfoot in children: diagnosis and treatment: a review. Zhou Binghua,Tang Kanglai,Hardy Mark Journal of orthopaedic surgery and research Talocalcaneal coalition often leads to a flatfoot deformity in children. Previous reports have uncovered many aspects of tarsal coalition and flatfoot respectively, including the etiology, clinical presentation, and diagnostic imaging, as well as treatment. However, the optimum surgical procedure for talocalcaneal coalition combined with flatfoot has not been definitively determined. The nonconformity of treatment options is due to our incomplete knowledge of biomechanics, diagnosis, and indication of treatment for talocalcaneal coalition with flatfoot. The objectives of this review are to provide an overview of the current knowledge about etiology, biomechanics, classification, diagnosis, and treatment options for talocalcaneal coalitions with flatfoot and highlight its therapies in children. 10.1186/s13018-014-0129-9
The operative correction of symptomatic flat foot deformities in children: the relationship between static alignment and dynamic loading. Westberry D E,Davids J R,Anderson J P,Pugh L I,Davis R B,Hardin J W The bone & joint journal At our institution surgical correction of symptomatic flat foot deformities in children has been guided by a paradigm in which radiographs and pedobarography are used in the assessment of outcome following treatment. Retrospective review of children with symptomatic flat feet who had undergone surgical correction was performed to assess the outcome and establish the relationship between the static alignment and the dynamic loading of the foot. A total of 17 children (21 feet) were assessed before and after correction of soft-tissue contractures and lateral column lengthening, using standardised radiological and pedobarographic techniques for which normative data were available. We found significantly improved static segmental alignment of the foot, significantly improved mediolateral dimension foot loading, and worsened fore-aft foot loading, following surgical treatment. Only four significant associations were found between radiological measures of static segmental alignment and dynamic loading of the foot. Weakness of the plantar flexors of the ankle was a common post-operative finding. Surgeons should be judicious in the magnitude of lengthening of the plantar flexors that is undertaken and use techniques that minimise subsequent weakening of this muscle group. 10.1302/0301-620X.95B5.30594
Determining treatment of flatfeet in children. Cappello T,Song K M Current opinion in pediatrics Infants are born with flexible flatfeet, and the normal arch develops in the first decade of life. Flexible flatfeet rarely cause disability, and asymptomatic children should not be burdened with orthotics or corrective shoes. Flexible flatfeet with tight heelcords may become symptomatic and can be addressed with a stretching program. Surgical intervention for flexible flatfeet is reserved for patients who have persistent localized symptoms despite conservative care. Rigid or pathologic flatfeet have multiple etiologies and many will require treatment to alleviate symptoms or improve function.
The long-term structural effect of orthoses for pediatric flexible flat foot: A systematic review. Choi Jun Young,Hong Woi Hyun,Suh Jin Soo,Han Jae Hwi,Lee Dong Joo,Lee Yong Jae Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons BACKGROUND:We aimed to evaluate the structural effects of the long-term use of orthoses for pediatric flexible flat foot (PFFF) using an algorithmic approach and a structured critical framework to assess the methodological quality of reported studies. METHODS:A comprehensive literature search using five databases, namely MEDLINE, the Cochrane Library, Scopus, the Web of Science, and EMBASE, was performed for pertinent articles published before March 30, 2018. Studies with quantitative data on the effects of the long-term use of orthoses for PFFF were included. The search strategy was adapted as appropriate for all other databases searched considering the differences in indexing terms and search syntax for each database. RESULTS:Randomized controlled trials and prospective cohort studies could not prove the estimated effects of orthoses on the medial longitudinal arch. They revealed that flexible flat feet in young children slowly improved with growth, regardless of the type of footwear used. However, three of four case series studies revealed that positive long-term effects could be achieved using orthoses. CONCLUSION:There is no strong evidence that the long-term use of orthoses improved the structural problem of PFFF. 10.1016/j.fas.2019.01.007
Flat foot functional evaluation using pattern recognition of ground reaction data. Bertani A,Cappello A,Benedetti M G,Simoncini L,Catani F Clinical biomechanics (Bristol, Avon) OBJECTIVE:Main purpose of this study was to apply quantitative gait analysis and statistical pattern recognition as clinical decision-making aids in flat foot diagnosis and post-surgery monitoring. DESIGN:Statistical pattern recognition techniques were applied to discriminate between normal and flat foot populations through ground reaction force measurements; ground reaction forces time course was assumed as a sensible index of the foot function. BACKGROUND:Gait analysis is becoming recognized as an important clinical tool in orthopaedics, in pre-surgery planning, post-surgery monitoring and in a posteriori evaluation of different treatment techniques. Statistical pattern recognition techniques have been utilized with success in this field to identify the most significant variables of selected motor functions in different pathologies, and to design classification rules and quantitative evaluation scores. METHODS:Ground reaction forces were recorded during free speed barefoot walks on 28 healthy subjects, and 28 symptomatic flexible flat foot children selected for surgical intervention. A new feature selection algorithm, based on heuristic optimization, was applied to select the most discriminant ground reaction forces time samples. A two-stage pattern recognition system, composed by three linear feature extractors, one for each ground reaction force component, and a linear classifier, was designed to classify the feet of each subject using the selected features. The output of the classifier was used to define a functional score. RESULTS:The classifier assigned the ground reaction force patterns performed by each subject into the right class with an estimated error of 15%, corresponding to an assignment error for each subject's foot of 9%. The most discriminant ground reaction forces time samples selected are in full agreement with the pathophysiology of the symptomatic flexible flat foot. The obtained score was utilized to monitor the 1 and 2 years post-operative functional recovery of two differently treated subgroups of 32 flexible flat foot subjects. CONCLUSIONS:Statistical pattern recognition techniques are promising tools for clinical gait analysis; the obtained score provides important functional information that could be used as a further aid in the clinical evaluation of flat foot and different surgical treatment techniques. RELEVANCE:Symptomatic flexible flat foot surgical decision making is frequently difficult because of the lack of objective criteria to assess functional abnormalities of the foot/ankle complex. Gait analysis and statistical pattern recognition can give us parameters with which to characterize "functional" flat foot. Moreover, we can objectively follow up the recovery of the foot/ankle complex function after surgical treatment. 10.1016/s0268-0033(98)90099-7
Segmental kinematic analysis of planovalgus feet during walking in children with cerebral palsy. Kruger Karen M,Konop Katherine A,Krzak Joseph J,Graf Adam,Altiok Haluk,Smith Peter A,Harris Gerald F Gait & posture Pes planovalgus (flatfoot) is a common deformity among children with cerebral palsy. The Milwaukee Foot Model (MFM), a multi-segmental kinematic foot model, which uses radiography to align the underlying bony anatomy with reflective surface markers, was used to evaluate 20 pediatric participants (30feet) with planovalgus secondary to cerebral palsy prior to surgery. Three-dimensional kinematics of the tibia, hindfoot, forefoot, and hallux segments are reported and compared to an age-matched control set of typically-developing children. Most results were consistent with known characteristics of the deformity and showed decreased plantar flexion of the forefoot relative to hindfoot, increased forefoot abduction, and decreased ranges of motion during push-off in the planovalgus group. Interestingly, while forefoot characteristics were uniformly distributed in a common direction in the transverse plane, there was marked variability of forefoot and hindfoot coronal plane and hindfoot transverse plane positioning. The key finding of these data was the radiographic indexing of the MFM was able to show flat feet in cerebral palsy do not always demonstrate more hindfoot eversion than the typically-developing hindfoot. The coronal plane kinematics of the hindfoot show cases planovalgus feet with the hindfoot in inversion, eversion, and neutral. Along with other metrics, the MFM can be a valuable tool for monitoring kinematic deformity, facilitating clinical decision making, and providing a quantitative analysis of surgical effects on the planovalgus foot. 10.1016/j.gaitpost.2017.03.020
Operative management options for symptomatic flexible adult acquired flatfoot deformity: a review. Zaw Htwe,Calder James D F Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 10.1007/s00167-009-1015-6
Classifications in Brief: Johnson and Strom Classification of Adult-acquired Flatfoot Deformity. Abousayed Mostafa M,Tartaglione Jason P,Rosenbaum Andrew J,Dipreta John A Clinical orthopaedics and related research 10.1007/s11999-015-4581-6
Evaluation and treatment of symptomatic pes planus. Yagerman Sarah E,Yeagerman Sarah E,Cross Michael B,Positano Rock,Doyle Shevaun M Current opinion in pediatrics PURPOSE OF REVIEW:To provide the pediatrician with a comprehensive synopsis of pediatric pes planus, also known as flatfoot. The term pes planus is a physical finding that generates some confusion in the medical community because it describes a spectrum of conditions that are diagnosed and managed differently. RECENT FINDINGS:Some of the recent data incorporated in this review come from pediatric, orthopaedic, and podiatric literature. These sources describe the clinical features and the latest treatment options for pes planus. SUMMARY:This article will provide some guidance to evaluate and treat the many causes of pediatric pes planus. Nonsurgical and operative management will be discussed. 10.1097/MOP.0b013e32834230b2
Posterior tibial tendon dysfunction. Geideman W M,Johnson J E The Journal of orthopaedic and sports physical therapy Posterior tibial tendon dysfunction is the most common cause of acquired flatfoot deformity in adults. Although this term suggests pathology involving only the posterior tibial tendon, the disorder includes a spectrum of pathologic changes involving associated tendon, ligament, and joint structures of the ankle, hindfoot, and midfoot. Early recognition and treatment is the key to prevention of the debilitating, long-term consequences of this disorder. Conservative care is possible in the earliest stages, whereas surgical reconstruction and eventually arthrodeses become necessary in the latter stages. The purpose of this article is to review the symptoms, physical examination, radiological examination, classification, and treatment of posterior tibial tendon dysfunction. 10.2519/jospt.2000.30.2.68
Prevalence of flat foot in preschool-aged children. Pfeiffer Martin,Kotz Rainer,Ledl Thomas,Hauser Gertrude,Sluga Maria Pediatrics OBJECTIVES:Our aim with this study was to establish the prevalence of flat foot in a population of 3- to 6-year-old children to evaluate cofactors such as age, weight, and gender and to estimate the number of unnecessary treatments performed. METHODS:A total of 835 children (411 girls and 424 boys) were included in this study. The clinical diagnosis of flat foot was based on a valgus position of the heel and a poor formation of the arch. Feet of the children were scanned (while they were in a standing position) by using a laser surface scanner, and rearfoot angle was measured. Rearfoot angle was defined as the angle of the upper Achilles tendon and the distal extension of the rearfoot. RESULTS:Prevalence of flexible flat foot in the group of 3- to 6-year-old children was 44%. Prevalence of pathological flat foot was < 1%. Ten percent of the children were wearing arch supports. The prevalence of flat foot decreases significantly with age: in the group of 3-year-old children 54% showed a flat foot, whereas in the group of 6-year-old children only 24% had a flat foot. Average rearfoot angle was 5.5 degrees of valgus. Boys had a significant greater tendency for flat foot than girls: the prevalence of flat foot in boys was 52% and 36% in girls. Thirteen percent of the children were overweight or obese. Significant differences in prevalence of flat foot between overweight, obese, and normal-weight children were observed. CONCLUSIONS:This study is the first to use a three-dimensional laser surface scanner to measure the rearfoot valgus in preschool-aged children. The data demonstrate that the prevalence of flat foot is influenced by 3 factors: age, gender, and weight. In overweight children and in boys, a highly significant prevalence of flat foot was observed; in addition, a retarded development of the medial arch in the boys was discovered. At the time of the study, > 90% of the treatments were unnecessary. 10.1542/peds.2005-2126
The role of leg muscles in variations of the arches in normal and flat feet. Gray E R Physical therapy 10.1093/ptj/49.10.1084
Rheumatoid flat foot and deformity of the first ray. Bouysset Maurice,Tebib Jacques,Noel Eric,Tavernier Thierry,Miossec Pierre,Vianey Jean-Claude,Duivon Jean-Pierre,Bonnin Michel,Nemoz Chantal,Jalby Jocelyne The Journal of rheumatology OBJECTIVE:To study the relationship between flat foot and forefoot deformities in rheumatoid arthritis (RA) in order to improve understanding of the progression of deformity and thus provide more appropriate treatment. METHODS:Anteroposterior and lateral weight-bearing radiographs were obtained of 308 feet of patients with RA and 202 feet of patients with neck pain (control feet). RESULTS:In women with RA, we observed with disease duration an increased frequency of flat foot that was correlated with first ray deformity (chiefly metatarsus primus adductus) and severe stages of disability. Flat foot increased very markedly after 3-4 years of disease duration. In control women, flat feet were more frequent after the age of 50 years. CONCLUSION:In RA the inflammatory and mechanical factors leading to foot deformity must receive early medical treatment to avoid progressive hindfoot deformities that lead to disability.
The effects of low arched feet on foot rotation during gait in children with Down syndrome. Galli M,Cimolin V,Rigoldi C,Pau M,Costici P,Albertini G Journal of intellectual disability research : JIDR BACKGROUND:In children with Down syndrome (DS) hypotonia and ligament laxity are characteristic features which cause a number of orthopaedic issues, such as flat foot. The aim of this study was to determine if children with flat foot are characterised by an accentuated external foot rotation during walking. METHOD:Fifty-five children with DS and 15 typically developing children recruited as control group were assessed using three-dimensional gait analysis, using an optoelectronic system, force platforms and video recording. Parameters related to foot rotation were identified and calculated and the participants' foot morphology was assessed using the arch index. RESULTS:Data obtained in this study showed that while DS children without flat foot displayed the foot position on the transverse plane globally close to controls during the whole gait cycle, the DS children with flat foot were characterised by higher extra-rotation of the foot in comparison with those without flat foot and controls. CONCLUSIONS:Our results suggest that the presence of flatfoot lead the children with DS to extra-rotate their feet more than the children without flat foot. From a clinical point of view, these results could enhance the rehabilitative programmes in DS. 10.1111/jir.12087
Effects of foot orthoses on gait patterns of flat feet patients. Chen Yu-Chi,Lou Shu-Zon,Huang Chen-Yu,Su Fong-Chin Clinical biomechanics (Bristol, Avon) BACKGROUND:Although foot orthotics are widely prescribed for the treatment of flatfoot, the biomechanical effects of such devices are not yet fully clear. Accordingly, this study conducted an experimental investigation to evaluate the effects of orthoses on the gait patterns of patients with flatfoot during level walking. METHODS:Eleven adults with flatfoot deformities were recruited. For each participant, kinematic and kinetic data were measured under three test conditions, i.e. walking barefoot, walking with shoes, and walking with shoes and insoles. During each test, the participants' gaits patterns were recorded and analyzed using a motion analysis system, two Kistler force plates and EVaRT software. FINDINGS:The results showed that walking with shoes and insoles and walking with shoes conditions increased the peak ankle dorsiflexion angle and moment, and also reduced the peak ankle plantarflexion angle and moment. Furthermore, walking with shoes and insoles and walking with shoes conditions increased the peak knee varus moment. The effects of the orthoese on knee and hip were minimal and no significant differences were observed between walking with shoes and insoles and walking with shoes. INTERPRETATION:The results suggested that the foot insoles and shoes developed in this study might benefit the ankle joint in patients with flat feet. In view of the minimal changes between walking with shoes and insoles and walking with shoes, further studies may be required to clarify the interaction between the foot and the insole/shoe. 10.1016/j.clinbiomech.2009.11.007
Lower Extremity Muscle Performance and Foot Pressure in Patients Who Have Plantar Fasciitis with and without Flat Foot Posture. International journal of environmental research and public health Abnormal foot posture and poor muscle performance are potential causes of plantar fasciitis (PF). However, no study has compared the differences between lower extremity muscle performance and foot pressure in patients who have PF with and without abnormal foot postures. This study aimed to compare the differences in lower extremity muscle performance, such as in the hip, quadriceps, hamstring, and plantar flexor, and foot pressure in patients who have PF with and without flat foot postures. Seventy patients with plantar heel pain were enrolled (37 flat feet and 33 without flat feet). The hip muscle strength was measured using a handheld digital dynamometer. The strength and reaction time of the quadriceps, hamstring, and plantar flexor muscles were evaluated using an isokinetic device. Foot pressure parameters were assessed using pedobarography. The strength of the plantar flexor muscles was significantly lower ( = 0.008), while the reaction time of the plantar flexor muscles was significantly faster ( = 0.007) for the involved feet of PF patients with flat feet than in those without flat feet. This study confirmed the differences in muscle performance between patients who have PF with different foot postures. Therefore, clinicians and therapists should plan treatment considering the differences in these characteristics for the management of these patients. 10.3390/ijerph20010087
Relationship between flat foot condition and gait pattern alterations in children with Down syndrome. Galli M,Cimolin V,Pau M,Costici P,Albertini G Journal of intellectual disability research : JIDR BACKGROUND:In patients with Down syndrome (DS) one of the most common abnormalities is flat foot which can interfere significantly with normal daily activities, such as gait. The aim of this study was to quantitatively assess the relationship between the flat foot and the gait alterations in DS children. METHOD:Twenty-nine patients with DS and 15 non-affected subjects were assessed using 3D Gait Analysis, using an optoelectronic system, force platforms and video recording. The degree of flat foot was assessed using the arch index and kinematic and kinetic parameters were identified and calculated from 3D Gait Analysis for each study participant. RESULTS:Data showed that ankle plantarflexion moment and ankle power during terminal stance were significant to differentiate the patients with and without flat feet: their peak values were significantly lower for the patients with flat foot. In addition, the research for correlation demonstrated that the higher the arch index value, the lower the peak of ankle moment and of the generated ankle power during terminal stance and the minimum of absorbed ankle power. CONCLUSIONS:Children with flat foot displayed a less functional gait pattern in terms of ankle kinetics than children without flat foot, suggesting that the presence of flat foot may lead to a weaker efficient walking. Then, the increasing flat foot tended to result in lower push-off ability, leading to a less functional walking. 10.1111/jir.12007
Correlation between primary flat foot and lower extremity rotational misalignment in adults. Cebulski-Delebarre A,Boutry N,Szymanski C,Maynou C,Lefebvre G,Amzallag-Bellenger E,Cotten A Diagnostic and interventional imaging PURPOSE:The goal of this study was to identify rotational abnormalities of the lower limb in adult patients with primary symptomatic flatfoot. MATERIALS AND METHODS:From September 2009 to May 2012, 24 patients (12 women, 12 men; mean age: 40 years) were prospectively included in the study. Each patient underwent radiographs of the flat foot and weight-bearing upright EOS examination. Three-dimensional reconstructions of the lower extremities were performed with derived measurements (length, hip and knee parameters, rotations). A total of 31 symptomatic primary flat feet (bilateral flat foot, n=7 patients; unilateral flat foot, n=17 patients) were studied and compared to 30 control subjects matched for age and gender. A comparison between the two groups was made with the Student t-test. RESULTS:No significant differences were found between patients and control subjects on the coronal and sagittal planes. Similarly, no significant differences were observed between the 2 groups for rotation of the lower limbs (femoral torsion, tibial torsion, tibiofemoral rotation). CONCLUSION:There are no rotational abnormalities of the lower extremities in adult patients with primary symptomatic flat foot. 10.1016/j.diii.2016.01.011
Flat-footedness is not a disadvantage for athletic performance in children aged 11 to 15 years. Tudor Anton,Ruzic Lana,Sestan Branko,Sirola Luka,Prpic Tomislav Pediatrics OBJECTIVE:Because the controversy about the relation of foot morphology and foot function is still present, we find it surprising that there are no studies published dealing with motor skills and athletic performance in flat-footed school children. Our aim in this study was to determine if there is an association between the degree of foot flatness and several motor skills that are necessary for sport performance. METHODS:The feet of 218 children aged 11 to 15 years were scanned, and the arch index was determined. The value of the arch index was corrected for the influence of age, and then the entire sample was categorized into 4 groups according to the flatness of their feet. The children were tested for eccentric-concentric contraction and hopping on a Kistler force platform, speed-coordination polygon (Newtest system), balance (3 tests), toe flexion (textile crunching), tiptoe standing angle, and repetitive leg movements. Altogether, 17 measures of athletic performance were measured. RESULTS:No significant correlations between the arch height and 17 motor skills were found. Categorizing the sample into 4 groups did not reveal any differences between the groups in athletic performance. Also, several multivariate analysis of variance sets of multiple independent variables referring to a particular motor ability were not found to be significant. The differences were not found even after comparing only the 2 extreme groups, meaning children with very low and children with very high arches. CONCLUSIONS:No disadvantages in sport performance originating from flat-footedness were confirmed. Children with flat and children with "normal" feet were equally successful at accomplishing all motor tests; thus, we suggest that there is no need for treatment of flexible flat feet with the sole purpose of improving athletic performance, as traditionally advised by many. 10.1542/peds.2008-2262
The effect of the degree of disability on nutritional status and flat feet in adolescents with Down syndrome. Jankowicz-Szymanska Agnieszka,Mikolajczyk Edyta,Wojtanowski Wiesław Research in developmental disabilities Excessive weight and obesity are ranked among lifestyle diseases. In the case of weight gain, the effectiveness of therapy based on diet and physical activity depends considerably on patients themselves, but despite this the number of those who successfully manage to lose weight is still not satisfactory. Preventing or treating excessive weight gain in the intellectually disabled is extremely difficult since they have a higher risk for developing obesity. The below presented study assessed the effect of the degree of intellectual disability on nutritional status in adolescents with Down syndrome. It also focused on some correlations between the degree of disability and a selected constituent of the body posture, i.e. flat feet. A total of 54 males and 26 females with mild and moderate Down syndrome, aged 18.68 ± 1.73, residents of Special Needs Education Centre in Tarnów, Poland, participated in the study, in which body weight and height, BMI, fat tissue percentage and the longitudinal arch of the foot were measured. A total of 17.5% of individuals with mild and 50% of individuals with moderate ID were found overweight or obese. Weight gain more often occurred in females. It seemed that flat feet were affected to a greater extent by the participants' nutritional status than their degree of disability. The study found no unambiguous effect of the degree of disability on the nutritional status and flat feet in individuals with Down syndrome. 10.1016/j.ridd.2013.08.016
Foot orthoses alter lower limb biomechanics but not jump performance in basketball players with and without flat feet. Journal of foot and ankle research BACKGROUND:Flat-footed individuals are believed to have poorer jump performance compared to normal-arched individuals. Foot orthoses are commonly used to support the deformed foot arch, and improve normal foot function. However, it is unclear if foot orthoses use affects jump performance in athletes. Our study aims to investigate if foot type and/or foot orthosis influence countermovement jump (CMJ) and standing broad jump (SBJ) performance and lower limb biomechanics. METHODS:Twenty-six male basketball players were classified into normal-arched ( = 15) or flat-footed ( = 11) groups using the Chippaux-Smirak index, navicular drop test, and the resting calcaneal angle measurement. They performed jumps with and without prefabricated foot orthoses. We measured jump height and distance for CMJ and SBJ, respectively. Hip, knee and ankle joint angles, angular velocities, moments and powers during take-off were also measured. RESULTS:For CMJ, the flat-footed group exhibited less ankle plantarflexion (  = 8.407,  = 0.008,  = 0.259 large effect) and less hip joint power (  = 7.416,  = 0.012,  = 0.244 large effect) than the normal-arched group. Foot orthoses reduced ankle eversion in both groups (  = 6.702,  = 0.016,  = 0.218 large effect). For SBJ, the flat-footed group produced lower peak hip angular velocity (  = 7.115,  = 0.013,  = 0.229 large effect) and generated lower horizontal GRF (  = 5.594,  = 0.026,  = 0.189 large effect) than the normal-arched group. Wearing foot orthoses reduced ankle eversion (  = 5.453,  = 0.028,  = 0.185 large effect), peak horizontal GRF (  = 13.672,  = 0.001,  = 0.363 large effect) and frontal plane ankle moment (  = 4.932,  = 0.036,  = 0.170 large effect). CONCLUSION:Foot type and the use of foot orthoses influence take-off biomechanics, but not actual CMJ and SBJ performances in basketball players. Compared to the normal-arched individuals, flat-footed athletes generated smaller propulsion GRF and lower hip flexion velocity and power, which suggests possible compensatory movement strategies to maximise jump performance. Future studies may investigate whether these altered biomechanics, taking into consideration their respective magnitude and effect sizes, may have implications on lower limb injuries. The use of foot orthoses resulted in biomechanical changes in both the normal-arched and flat-footed groups but does not enhance jumping performance. 10.1186/s13047-019-0334-1
Knee and ankle biomechanics with lateral wedges with and without a custom arch support in those with medial knee osteoarthritis and flat feet. Hatfield Gillian L,Cochrane Christopher K,Takacs Judit,Krowchuk Natasha M,Chang Ryan,Hinman Rana S,Hunt Michael A Journal of orthopaedic research : official publication of the Orthopaedic Research Society UNLABELLED:This study compared immediate changes in knee and ankle/subtalar biomechanics with lateral wedge orthotics with and without custom arch support in people with knee osteoarthritis and flat feet. Twenty-six participants with radiographic evidence of medial knee osteoarthritis (22 females; age 64.0 years [SD 8.0 years], BMI 27.2 kg/m(2) [4.2]) and flat feet (median foot posture index = + 5) underwent three-dimensional gait analysis for three conditions: Control (no orthotic), lateral wedge, and lateral wedge plus arch support. Condition order was randomized. Outcomes included frontal plane knee and ankle/subtalar biomechanics, and comfort. Compared to the control, lateral wedge and lateral wedge with arch support reduced the knee adduction moment impulse by 8% and 6%, respectively (p < 0.05). However, the lateral wedge resulted in a more everted foot position (4.3 degrees) than lateral wedge plus arch support (3.2 degrees) (p < 0.05). In contrast, lateral wedge plus arch support reduced foot frontal plane excursion compared to other conditions (p < 0.05). Participants self-reported significantly more immediate comfort with lateral wedge plus arch support compared to the control, whereas there was no difference in self-reported comfort between lateral wedge and control. No immediate changes in knee pain were observed in any condition. CLINICAL SIGNIFICANCE:Rather than prescribing lateral wedges to all patients with knee osteoarthritis, those who have medial knee osteoarthritis and flat feet may prefer to use the combined orthotic to reduce loads across the knee, and to minimize the risk of foot and ankle symptoms as a consequence of orthotic treatment. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1597-1605, 2016. 10.1002/jor.23174
Adult Acquired Flatfoot Deformity. Jackson J Benjamin,Pacana Matthew J,Gonzalez Tyler A The Journal of the American Academy of Orthopaedic Surgeons Adult acquired flatfoot deformity (AAFD) is a condition commonly seen by orthopaedic surgeons. Posterior tibial tendon dysfunction is thought to be the initial pathoanatomic etiology that leads to this deformity. Successful resolution of the pain associated with AAFD can be achievable with nonsurgical methods. Patients who continue to have pain or functional limitations despite nonsurgical treatment can find improvement with appropriately selected surgical interventions. This article addresses new advances in treatment based on the stage of AAFD and will identify areas of continued development with a focus on surgical management. The literature continues to evolve as demonstrated by a recent update regarding the nomenclature and treatment of this condition to progressive collapsing flatfoot deformity. Future goals of research include understanding the natural history of the disease, from asymptomatic to symptomatic, and studying a wide array of newer treatments and implants that have not been prospectively evaluated. 10.5435/JAAOS-D-21-00008
Non-surgical interventions for paediatric pes planus. Rome Keith,Ashford Robert L,Evans Angela The Cochrane database of systematic reviews BACKGROUND:Paediatric pes planus ('flat feet') is a common childhood condition with a reported prevalence of 14%. Flat feet can result in pain and altered gait. No optimal strategy for non-surgical management of paediatric flat feet has been identified. OBJECTIVES:To assess the effectiveness of non-surgical interventions for treatment of paediatric pes planus (flat feet). SEARCH STRATEGY:We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, CINAHL, Index to Theses, and Dissertation Abstracts (up to June 2009). SELECTION CRITERIA:All randomised and quasi-randomised trials of non-surgical interventions for paediatric pes planus were identified. The primary outcomes were pain reduction and adverse events; secondary outcomes included disability involving the foot, goniometric measurements, quality of life and patient comfort. DATA COLLECTION AND ANALYSIS:Two authors independently extracted data and assessed the risk of bias of included trials. MAIN RESULTS:Three trials involving 305 children were included in this review. Due to clinical heterogeneity, data were not pooled. All trials had potential for bias. Data from one trial (40 children with juvenile arthritis and foot pain) indicated that use of custom-made orthoses compared with supportive shoes alone resulted in significantly greater reduction in pain intensity (mean difference (MD) -1.5 points on a 10-point visual analogue scale (VAS), 95% CI -2.8 to -0.2; number need to treat to benefit (NNTB) 3, 95% CI 2 to 23), and reduction in disability (measured using the disability subscale of the Foot Function Index on a 100mm scale (MD -18.65mm, 95% CI -34.42 to -2.68mm). The second trial of seven to 11 year old children with bilateral flat feet (n = 178) found no difference in the number of participants with foot pain between custom-made orthoses, prefabricated orthoses and the control group who received no treatment. A third trial of one to five year olds with bilateral flat feet (n=129) did not report pain at baseline but reported the subjective impression of pain reduction after wearing shoes. No adverse effects were reported in the three trials. AUTHORS' CONCLUSIONS:The evidence from randomised controlled trials is currently too limited to draw definitive conclusions about the use of non-surgical interventions for paediatric pes planus. Future high quality trials are warranted in this field. Only limited interventions commonly used in practice have been studied and there is much debate over the treatment of symptomatic and asymptomatic pes planus. 10.1002/14651858.CD006311.pub2
An investigation into the aetiology of flexible flat feet: the role of subtalar joint morphology. Kothari A,Bhuva S,Stebbins J,Zavatsky A B,Theologis T The bone & joint journal AIMS:There is increasing evidence that flexible flatfoot (FF) can lead to symptoms and impairment in health-related quality of life. As such we undertook an observational study investigating the aetiology of this condition, to help inform management. The hypothesis was that as well as increased body mass index (BMI) and increased flexibility of the lower limb, an absent anterior subtalar articulation would be associated with a flatter foot posture. PATIENTS AND METHODS:A total of 84 children aged between eight and 15 years old were prospectively recruited. The BMI for each child was calculated, flexibility was assessed using the lower limb assessment scale (LLAS) and foot posture was quantified using the arch height index (AHI). Each child underwent a sagittal T1-weighted MRI scan of at least one foot. RESULTS:An absent anterior subtalar articulation (p < 0.001) and increased LLAS (p = 0.001) predicted a low AHI. BMI was not a significant predictive factor (p = 0.566). CONCLUSION:This is the first study to demonstrate the importance of the morphology of the subtalar joint on the underlying foot posture in vivo. TAKE HOME MESSAGE:Flexibility of the lower limb and absence of the anterior facet of the subtalar joint are associated with flexible FF and may influence management of this common condition. 10.1302/0301-620X.98B4.36059
Do foot orthoses change lower limb muscle activity in flat-arched feet towards a pattern observed in normal-arched feet? Murley George S,Landorf Karl B,Menz Hylton B Clinical biomechanics (Bristol, Avon) BACKGROUND:One of the hypothesised mechanisms by which foot orthoses obtain their clinical effect is by influencing muscle activity, however previous studies have reported highly variable findings. The aim of this study was to determine whether orthoses change muscle activity in people with flat-arched feet towards a pattern observed in people with normal-arched feet. METHODS:Thirty young asymptomatic adults with flat-arched feet were recruited. Foot posture was classified using two clinical measurements and four skeletal alignment measurements from weight-bearing foot x-rays. Electromyographic activity was recorded while walking from tibialis posterior and peroneus longus via in-dwelling wire electrodes, and from tibialis anterior and medial gastrocnemius via surface electrodes. Four experimental conditions were assessed: (i) barefoot, (ii) shoe only, (iii) a heat-moulded (modified) prefabricated foot orthosis, and (iv) a 20-degree inverted-style customised foot orthosis. FINDINGS:During the contact phase of gait, tibialis posterior electromyographic amplitude decreased significantly with the prefabricated orthosis (peak amplitude - 19% decrease, P=0.007; RMS amplitude--22% decrease, P=0.002) and the customised orthosis (peak amplitude--12% decrease, P<0.001, RMS amplitude--13% decrease, P=0.001), compared with the shoe-only condition. During the midstance/propulsive phase, peroneus longus electromyographic amplitude increased significantly with the prefabricated orthosis, compared with the shoe-only (peak amplitude--21% increase, P=0.024; RMS amplitude--24% increase, P=0.019) and customised orthosis conditions (peak amplitude--16% increase, P=0.028). INTERPRETATION:The foot orthoses significantly altered tibialis posterior and peroneus longus electromyographic amplitude. However, only the modified prefabricated orthosis changed peroneus longus electromyographic amplitude towards a pattern observed with normal-arched feet. Otherwise, few differences were found between the modified prefabricated and customised orthoses. Further research is required to determine whether these changes in muscle function are associated with clinical outcomes. 10.1016/j.clinbiomech.2010.05.001
Predictors of the Biomechanical Effects of Customized Foot Orthoses in Adults With Flat-Arched Feet. Arnold John B,May Thomas,Bishop Christopher Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine OBJECTIVE:To determine the potential presence and characteristics of biomechanical responders to customized foot orthoses during walking in adults with flat-arched feet. DESIGN:Experimental, repeated-measures. SETTING:University clinic and laboratory. PARTICIPANTS:Eighteen symptom-free adults with flat-arched feet. INTERVENTIONS:Customized foot orthoses. MAIN OUTCOME MEASURES:In-shoe foot biomechanics were measured during walking with and without customized foot orthoses using 3D analysis. Selected kinematic and kinetic variables during baseline walking were compared between subgroups who displayed reductions in calcaneal eversion with foot orthoses to those with no change or increases. RESULTS:Biomechanical responders displayed significantly greater peak calcaneal eversion (+2.2 degrees, P = 0.009). Time to peak calcaneal eversion (-11%, P = 0.006), peak dorsiflexion of the hallux (-6 degrees, P = 0.001), and medial-lateral excursion of the center of pressure during loading response were all reduced in the responder subgroup (-2 mm, P ≤ 0.001). Variables significantly different between subgroups were moderately associated with the response to foot orthoses (canonical correlation = 0.687, effect size = 0.47, P = 0.063). CONCLUSIONS:Individuals with increased dynamic foot pronation were more likely to show a favorable biomechanical response to customized foot orthoses, providing preliminary evidence to support the stratified use of foot orthoses to optimize their effectiveness. 10.1097/JSM.0000000000000461
The feet of overweight and obese young children: are they flat or fat? Mickle Karen J,Steele Julie R,Munro Bridget J Obesity (Silver Spring, Md.) OBJECTIVE:The purpose of this study was to determine whether the flat feet displayed by young obese and overweight children are attributable to the presence of a thicker midfoot plantar fat pad or a lowering of the longitudinal arch relative to that in non-overweight children. RESEARCH METHODS AND PROCEDURES:Foot anthropometry, an arch index derived from plantar footprints, and midfoot plantar fat pad thickness measured by ultrasound were obtained for 19 overweight/obese preschool children (mean age, 4.3 +/- 0.9 years; mean height, 1.07 +/- 0.1 m; mean BMI, 18.6 +/- 1.2 kg/m(2)) and 19 non-overweight children matched for age, height, and sex (mean age, 4.3 +/- 0.7 years; mean height, 1.05 +/- 0.1 m; mean BMI, 15.7 +/- 0.7 kg/m(2)). RESULTS:Independent t tests revealed no significant between-subject group differences (p = 0.39) in the thickness of the midfoot plantar fat pad. However, the overweight/obese children had a significantly lower plantar arch height (0.9 +/- 0.3 cm) than their non-overweight counterparts (1.1 +/- 0.2 cm; p = 0.04). DISCUSSION:The lower plantar arch height found in the overweight/obese children suggests that the flatter feet characteristic of overweight/obese preschool children may be caused by structural changes in their foot anatomy. It is postulated that these structural changes, which may adversely affect the functional capacity of the medial longitudinal arch, might be exacerbated if excess weight bearing continues throughout childhood and into adulthood. 10.1038/oby.2006.227
Association of flat feet with knee pain and cartilage damage in older adults. Gross K Douglas,Felson David T,Niu Jingbo,Hunter David J,Guermazi Ali,Roemer Frank W,Dufour Alyssa B,Gensure Rebekah H,Hannan Marian T Arthritis care & research OBJECTIVE:To assess the cross-sectional relation of planus foot morphology to ipsilateral knee pain and compartment-specific knee cartilage damage in older adults. METHODS:In the Framingham Studies, we adapted the Staheli Arch Index (SAI) to quantify standing foot morphology from pedobarographic recordings. We inquired about knee pain and read 1.5 T magnetic resonance image (MRI) scans using the Whole-Organ MRI Score. Logistic regression compared the odds of knee pain among the most planus feet to the odds among all other feet, and estimated odds within categories of increasing SAI. Similar methods estimated the odds of cartilage damage in each knee compartment. Generalized estimating equations adjusted for age, sex, body mass index, and nonindependent observations. RESULTS:Among 1,903 participants (56% women, mean ± SD age 65 ± 9 years), 22% of knees were painful most days. Cartilage damage was identified in 45% of medial tibiofemoral (TF), 27% of lateral TF, 58% of medial patellofemoral (PF), and 42% of lateral PF compartments. Compared with other feet, the most planus feet had 1.3 times (95% confidence interval [95% CI] 1.1-1.6) the odds of knee pain (P = 0.009), and 1.4 times (95% CI 1.1-1.8) the odds of medial TF cartilage damage (P = 0.002). Odds of pain (P for linear trend = 0.05) and medial TF cartilage damage (P for linear trend = 0.001) increased linearly across categories of increasing SAI. There was no association between foot morphology and cartilage damage in other knee compartments. CONCLUSION:Planus foot morphology is associated with frequent knee pain and medial TF cartilage damage in older adults. 10.1002/acr.20431
The posterior tibial tendon and the tarsal sinus in rheumatoid flat foot: magnetic resonance imaging of 40 feet. Jernberg E T,Simkin P,Kravette M,Lowe P,Gardner G The Journal of rheumatology OBJECTIVE:To investigate the role of the posterior tibial tendon in the flat foot deformity of rheumatoid arthritis (RA). METHODS:Eleven patients with hyperpronated feet and 9 without hyperpronation underwent magnetic resonance imaging (MRI) of the feet and ankles. Radial oblique double echo images provided cross sectional views of the posterior tibial tendon as it coursed behind and under the medial malleolus and inserted beneath the midfoot. RESULTS:Complete tears (Type III) of the posterior tibial tendon were seen in one patient with hyperpronation and in one without hyperpronation. However, partial tears (Types I and II) of the posterior tibial tendon were common, and when Type I-III posterior tibial tendon tears were grouped together, they were seen in 68% of flat feet and in 43% of feet that were not flat. Abnormalities of the tarsal sinus, including cortical erosions and replacement of the normal fat signal with intermediate signal soft tissue, were seen in 74% of flat feet and in 5% of feet that were not flat. CONCLUSION:Posterior tibial tendon tears are common in RA flat feet, but are usually incomplete and are not solely responsible for the flat foot deformity.
The biomechanical effects of 3D printed and traditionally made foot orthoses in individuals with unilateral plantar fasciopathy and flat feet. Gait & posture BACKGROUND:Foot orthoses (FOs) are used to manage foot pathologies such as plantar fasciopathy. 3D printed custom-made FOs are increasingly being manufactured. Although these 3D-printed FOs look like traditionally heat-moulded FOs, there are few studies comparing FOs made using these two different manufacturing processes. RESEARCH QUESTION:How effective are 3D-printed FOs (3D-Print) compared to traditionally-made (Traditional) or no FOs (Control), in changing biomechanical parameters of flat-footed individuals with unilateral plantar fasciopathy? METHODS:Thirteen participants with unilateral plantar fasciopathy walked with shoes under three conditions: Control, 3D-print, and Traditional. 2 × 3 repeated measures analysis of variance (ANOVAs) with Bonferroni post-hoc tests were used to compare discrete kinematic and kinetic variables between limbs and conditions. Waveform analyses were also conducted using statistical parametric mapping (SPM). RESULTS:There was a significant condition main effect for arch height drop (p = 0.01; ηp =0.54). There was 0.87 mm (95% CI [-1.84, -0.20]) less arch height drop in 3D-print compared to Traditional. The SPM analyses revealed condition main effects on ankle moment (p < 0.001) and ankle power (p < 0.001). There were significant differences between control condition and both 3D-print and Traditional conditions. For ankle moment and power, there were no differences between 3D-print and Traditional conditions. SIGNIFICANCE:3D-printed FOs are more effective in reducing arch height drop, whist both FOs lowered ankle plantarflexion moment and power compared to no FOs. The results support the use of 3D-printed FOs as being equally effective as traditionally-made FOs in changing lower limb biomechanics for a population of flat-footed individuals with unilateral plantar fasciopathy. 10.1016/j.gaitpost.2022.06.006
Quantifying lower limb inter-joint coordination and coordination variability after four-month wearing arch support foot orthoses in children with flexible flat feet. Jafarnezhadgero AmirAli,Mousavi Seyed Hamed,Madadi-Shad Morteza,Hijmans Juha M Human movement science INTRODUCTION:Flat feet in children negatively affect lower limb alignment and cause adverse health-related problems. The long-term application of foot orthoses (FOs) may have the potential to improve lower limb coordination and its variability. AIM:To evaluate the effects of long-term use of arch support FOs on inter-joint coordination and coordination variability in children with flexible flat feet. METHODS:Thirty boys with flexible flat feet were randomly assigned to the experimental (EG) and control groups. The EG used medial arch support FOs during daily activities over a four-month period while the control group received a flat 2-mm-thick insole for the same time period. Lower-limb coordination and variability during the 3 sub-stance phases were quantified using a vector coding technique. RESULTS:Frontal plane ankle-hip coordination in EG during mid-stance changed to an anti-phase pattern (156.9) in the post-test compared to an in-phase (221.1) in the pre-test of EG and post-test of CG (222.7). Frontal plane knee-hip coordination in EG during loading response (LR) changed to an anti-phase pattern (116) in the post-test compared to an in-phase (35.5) in the pre-test of EG and post-test of CG (35.3). Ankle inversion/eversion-knee internal/external rotation joint coupling angle in EG changed to an in-phase pattern (59) in the post-test compared to a proximal phase (89) in the pre-test. Coupling angle variability increased in the post-test of EG for sagittal plane ankle-hip during push-off, transverse plane ankle-hip during LR and mid-stance, and transverse plane knee-hip during LR and mid-stance compared to pre-test of EG and post-test of CG. CONCLUSION:The long-term use of arch support FOs proved to be effective to alter lower limb coordination and coordination variability during walking in children with flexible flat feet. This new insight into coordinative function may be useful for improving corrective exercise strategies planned for children with flat feet. 10.1016/j.humov.2020.102593
Long-term clinical and radiological outcomes following surgical treatment for symptomatic pediatric flexible flat feet: a systematic review. Acta orthopaedica BACKGROUND AND PURPOSE:Albeit pediatric flexible flat foot (FFF) is a common condition, only a minority of patients become symptomatic. Long-term outcomes of surgically treated pediatric patients with symptomatic FFF are largely unknown. In this systematic review, studies providing outcomes at a mean follow-up of at least 4 years after the procedure in these patients were analyzed. MATERIAL AND METHODS:A PubMed search was undertaken involving original articles published up to July 2021 on outcome in children aged 6 to 14 with surgically treated FFF and mean (or minimum) follow-up of at least 4 years. Radiographic and clinical outcomes were analyzed. RESULTS:Of initially 541 entries, 10 could be included in the systematic review (all level IV), involving 846 pediatric patients with 1,536 symptomatic FFF. Pooled mean radiological (n = 8) and clinical follow-up (n = 10) was 5.3 (range 0.5-15) and 7.0 (range 4.1-15) years, respectively. Surgical procedures included arthroereisis (n = 8), lateral column lengthening (n = 1), and Horseman procedure (n = 1). Overall relative frequency of implant-associated complications and wound-healing problems was 3.2% and 1.3%, as well as 2.8% and 1.6% following subtalar arthroereisis only. From preoperative to latest radiological assessment following subtalar arthroereisis (including 3 studies with radiological follow-up < 48 months), pooled median decrease in talonavicular coverage angle (TNCA; -9.2°), anteroposterior talocalcaneal angle (A-TCA; -6.5°), lateral talocalcaneal angle (L-TCA; -3.5°), talar declination angle (TDA; -14°), Moreau Costa Bertani angle (MCB; -13°), and talo-firstmetatarsal angle (L-T1MA; -10°) was observed, as was an increase in calcaneal pitch (4.5°). INTERPRETATION:In symptomatic pediatric FFF patients, surgery is associated with a manageable complication profile, and results in satisfactory long-term clinical as well as radiological outcome. Yet scientific evidence is low, warranting larger scaled studies in the future. 10.2340/17453674.2022.2254
Effect of functional fatigue on vertical ground-reaction force in individuals with flat feet. Boozari Sahar,Jamshidi Ali Ashraf,Sanjari Mohammad Ali,Jafari Hassan Journal of sport rehabilitation CONTEXT:Flat foot is one of the lower extremity deformities that might change kinetic variables of gait. Fatigue is one of the factors that can alter the vertical ground-reaction force (GRF). The effect of a fatiguing condition on vertical GRF has not been documented in individuals with flat feet. OBJECTIVE:To examine the fatigue effect on vertical GRF in individuals with flat feet compared with a normal group during barefoot walking. DESIGN:Repeated-measure ANOVA for the effects of fatigue on individuals with flat feet and normal feet. SETTING:Biomechanics laboratory. PARTICIPANTS:17 subjects with flat feet and 17 normal subjects (recruited according to their arch-height ratio). MAIN OUTCOME MEASURES:Three vertical GRF measures (F1, the first peak force; F2, minimum force; and F3, the second peak force) were extracted before and after a functional fatigue protocol. RESULTS:No significant interaction between fatigue and group was observed for the 3 vertical GRF measures. For F2, fatigue and group effects were significant (P = .001 and P = .02, respectively). Furthermore, F2 was higher in the flat-feet group than in the normal group; F2 also increased after fatigue. For F3, only a significant fatigue effect was observed (P = .004). F3 decreased after fatigue in both groups. CONCLUSIONS:In the flat-feet group, a decrease in the variation of vertical GRF might be due to more flexible foot joints. After fatigue, muscles might lose their ability to control the foot joints and cause higher F2 in the flat-feet group. 10.1123/jsr.22.3.177
Differences in plantar loading between flat and normal feet during different athletic tasks. Queen Robin M,Mall Nathan A,Nunley James A,Chuckpaiwong Bavornrit Gait & posture The purpose of this study was to determine if foot type (flat or normal) resulted in loading differences during four sport-specific tasks (cross-cut, side-cut, shuttle run, and landing from a simulated lay-up). Twenty-two healthy subjects (12 normal feet and 10 flat feet) completed five trials in each condition, while in-shoe pressure data was collected at 50 Hz. Contact area, maximum force, and the force time integral were analyzed under the entire foot and in eight-foot regions. Foot type was determined by examining navicular height, arch angle, rearfoot angle, and a clinical score. A series of independent sample t-tests were used to determine statistical differences (alpha<0.05). During the cross-cut, flat feet demonstrated an increase in medial midfoot contact area. During the side-cut, flat feet demonstrated an increase in contact area, force time integral and maximum force in both the medial and lateral midfoot. During the shuttle run, flat feet demonstrated an increase in force time integral in the lateral midfoot and increases in maximum force in both the medial and lateral midfoot. During the landing task, flat feet demonstrated an increase in maximum force in the medial midfoot. However, flat feet demonstrate a decrease in middle forefoot maximum force. All results were statistically significant (p<0.05). Therefore, individuals with a normal foot could be at a lower risk for medial and lateral midfoot injuries such as metatarsal stress fractures, indicating that foot type should be assessed when determining an individual's risk for metatarsal stress fractures. 10.1016/j.gaitpost.2008.12.010
Are the feet of obese children fat or flat? Revisiting the debate. Riddiford-Harland D L,Steele J R,Baur L A International journal of obesity (2005) OBJECTIVE:There is debate as to the effects of obesity on the developing feet of children. We aimed to determine whether the flatter foot structure characteristic of obese primary school-aged children was due to increased medial midfoot plantar fat pad thickness (fat feet) or due to structural lowering of the longitudinal arch (flat feet). METHODS AND PROCEDURES:Participants were 75 obese children (8.3 ± 1.1 years, 26 boys, BMI 25.2 ± 3.6 kg m(-2)) and 75 age- and sex-matched non-obese children (8.3 ± 0.9 years, BMI 15.9 ± 1.4 kg m(-2)). Height, weight and foot dimensions were measured with standard instrumentation. Medial midfoot plantar fat pad thickness and internal arch height were quantified using ultrasonography. RESULTS:Obese children had significantly greater medial midfoot fat pad thickness relative to the leaner children during both non-weight bearing (5.4 and 4.6 mm, respectively; P<0.001) and weight bearing (4.7 and 4.3 mm, respectively; P < 0.001). The obese children also displayed a lowered medial longitudinal arch height when compared to their leaner counterparts (23.5 and 24.5 mm, respectively; P = 0.006). CONCLUSION:Obese children had significantly fatter and flatter feet compared to normal weight children. The functional and clinical relevance of the increased fatness and flatness values for the obese children remains unknown. 10.1038/ijo.2010.119
Surgical procedures for treatment of adult acquired flatfoot deformity: a network meta-analysis. Tao Xu,Chen Wan,Tang Kanglai Journal of orthopaedic surgery and research BACKGROUND:Adult acquired flatfoot deformity (AAFD) represents a spectrum of deformities affecting the foot and the ankle. The optimal management of AAFD remains controversial. We evaluated the efficacy of surgical treatments of AAFD using both direct and indirect evidences. METHODS:We searched PubMed, EmBase, and the Cochrane Library to identify eligible studies conducted through November 2018. To compare different surgical strategies, we performed a network meta-analysis. A traditional meta-analysis using a random-effects model was used to evaluate the pooled outcome. RESULTS:A total of 21 studies including 498 patients were collected and analyzed. Network meta-analysis results based on lateral angle talocalcaneal-calcaneal pitch (LAT-CP) indicated that medial displacement calcaneal osteotomy (MDCO) has the highest probability to be the best course of AAFD treatment. However, analyses based on anteroposterior talo-first metatarsal (AP-TMT1) and lateral angle talocalcaneal talo-first metatarsal (LAT-TMT1) suggested that lateral column lengthening (LCL) was the best treatment, while those based on lateral angle talocalcaneal-arch height, anteroposterior talocalcaneal (AP-TC), lateral angle talocalcaneal-talocalcaneal (LAT-TC), anteroposterior-talonavicular coverage (AP-TNC), talonavicular coverage (TNC), and the American Orthopedic Foot and Ankle Society (AOFAS) indicated triple arthrodesis (TAO) as the best treatment. Moreover, double arthrodesis (DAO) provided the best treatment effect on the function score. Furthermore, according to traditional meta-analysis, the summary of standardized mean differences (SMD) indicated that the surgical interventions are associated with significant improvements in LAT-CP (SMD - 1.78), LAT-arch height (SMD - 4.95), AOFAS (SMD - 5.24), AP-TMT1 (SMD 2.45), LAT-TMT1 (SMD 1.97), AP-TC (SMD 3.05), LAT-TC (SMD 2.20), AP-TNC (SMD 2.07), TNC (SMD 1.70), and function score (SMD 0.95). CONCLUSIONS:Our findings indicated that MDCO, LCL, TAO, or DAO might be the best surgical approaches for AAFD treatment. Furthermore, patients who received surgical interventions had significant improvements in symptoms and function. 10.1186/s13018-019-1094-0
Are flexible flat feet associated with proximal joint problems in children? Kothari A,Dixon P C,Stebbins J,Zavatsky A B,Theologis T Gait & posture The role of flexible flat feet (FF) in the development of musculoskeletal symptoms at joints proximal to the ankle is unclear. We undertook an observational study to investigate the relationship between foot posture and the proximal joints in children. It was hypothesised that reduced arch height would be associated with proximal joint symptoms and altered gait kinematics and kinetics particularly in the transverse plane at the hip and knee. Ninety-five children between the ages of 8-15 were recruited into this ethically approved study. Foot posture was classified using the arch height index (AHI). The frequency of knee and hip/back pain was documented, and each child underwent three dimensional gait analysis. Reduced arch height was associated with increased odds of knee symptoms (p<0.01) and hip/back symptoms (p=0.01). A flat foot posture was also significantly associated with a reduction in the second peak of the vertical ground reaction force (p=0.03), which concomitantly affected late stance hip and knee moments. A reduced AHI was also associated with increased pelvic retraction and increased knee valgus in midstance. No kinematic and kinetic parameter associated with a flat foot posture related to increased proximal joint symptoms in the FF group. Children with a flatter foot posture are more likely to have pain or discomfort at the knee, hip and back; however, the mechanisms by which this occurs remain unclear. Treating FF without explicit understanding of how it relates to symptoms is difficult, and further work in this area is required. 10.1016/j.gaitpost.2016.02.008
Flatfoot deformity in children and adolescents: surgical indications and management. Bouchard Maryse,Mosca Vincent S The Journal of the American Academy of Orthopaedic Surgeons Most children with flatfeet are asymptomatic and will never require treatment. In general, flatfoot deformity is flexible and will not cause pain or disability; it is a normal variant of foot shape. Thus, it is essential to reassure and educate patients and parents. A flatfoot with a contracture of the Achilles tendon may be painful. In these cases, a stretching program may help relieve pain. Scant convincing evidence exists to support the use of inserts or shoe modifications for effective relief of symptoms, and there is no evidence that those devices change the shape of the foot. The surgeon must be vigilant to identify the rare rigid flatfoot. Indications for flatfoot surgery are strict: failure of prolonged nonsurgical attempts to relieve pain that interferes with normal activities and occurs under the medial midfoot and/or in the sinus tarsi. In nearly all cases, an associated contracture of the heel cord is present. Osteotomies with supplemental soft-tissue procedures are the best proven approach for management of [corrected] flatfoot. 10.5435/JAAOS-22-10-623
Flexible flat feet in children: a real problem? García-Rodríguez A,Martín-Jiménez F,Carnero-Varo M,Gómez-Gracia E,Gómez-Aracena J,Fernández-Crehuet J Pediatrics OBJECTIVES:To estimate the prevalence of flexible flat feet in the provincial population of 4- to 13-year-old schoolchildren and the incidence of treatments considered unnecessary. SETTING:Province of Málaga, Spain. METHODS:We examined and graded by severity a sample of 1181 pupils taken from a total population of 198 858 primary schoolchildren (CI: 95%; margin of error: 5%). The sample group was separated into three 2-year age groups: 4 and 5 years, 8 and 9 years, and 12 and 13 years. The plantar footprint was classified according to Denis1 into three grades of flat feet: grade 1 in which support of the lateral edge of the foot is half that of the metatarsal support; grade 2 in which the support of the central zone and forefoot are equal; and grade 3 in which the support in the central zone of the foot is greater than the width of the metatarsal support. The statistical analysis for the evaluation of the differences between the groups was performed with Student's t and chi2 tests as appropriate. RESULTS:The prevalence of flat feet was 2.7%. Of the 1181 children sampled, 168 children (14.2%) were receiving orthopedic treatment, but only 2.7% had diagnostic criteria of flat feet. When we inspected the sample, we found that a number of children were being treated for flat feet with boots and arch supports. Most of them did not have a flat plantar footprint according to the criteria that we used for this work. Furthermore, in the group of children that we diagnosed as having flat feet, only 28.1% were being treated. We found no significant differences between the number of children receiving orthopedic treatments and the presence or absence of a flat plantar footprint. Children who were overweight in the 4- and 5-year-old group showed an increased prevalence for flat feet as diagnosed by us. CONCLUSION:The data suggest that an excessive number of orthopedic treatments had been prescribed in the province. When extrapolated to the 1997 population of schoolchildren within the age groups studied the figures suggested that approximately 28 167 children in Málaga province probably would have been receiving orthopedic treatments with boots and insoles at the time of our study. Consequently, the total expenditure on orthopedic boots and insoles that year could be estimated as 676 008 000 pesetas ($4 447 422 in US currency). 10.1542/peds.103.6.e84
Kinematic differences between neutral and flat feet with and without symptoms as measured by the Oxford foot model. Kerr C M,Zavatsky A B,Theologis T,Stebbins J Gait & posture BACKGROUND:Flatfoot is a common presentation in children. It is usually asymptomatic, though a small number of children experience pain. Foot function during flatfoot walking is rarely considered, yet as an activity that places significant demands on the feet, this could explain the differences in terms of symptoms. RESEARCH QUESTION:This paper investigates walking patterns in neutral and flat feet, with and without symptoms, to determine which kinematic parameters are associated with symptomatic flat feet. METHODS:This is a retrospective study in which one hundred and six children between five and 18 years old were assessed by a physiotherapist for foot posture. Each foot was classified into one of four groups, giving 98 asymptomatic neutral, 47 asymptomatic mild flat, 29 asymptomatic flat, and 38 symptomatic flat feet with complete data for analysis. Using Plug-In-Gait and Oxford-Foot-Model markers, walking kinematics were measured, along with ground reaction forces. Median values of 14 lower limb joint angles were calculated at foot strike, midstance, and foot off. Each foot was treated as an independent sample. ANOVA and ANCOVA (with the speed-related variable relative stride length as the covariate) and post-hoc tests were used to assess whether angles differed between groups. RESULTS:The symptomatic flat feet showed significant differences from asymptomatic groups (most commonly the neutral feet) in terms of hip flexion, knee flexion and varus, hindfoot inversion-eversion, and forefoot abduction-adduction. Increased forefoot abduction occurred throughout stance phase in symptomatic flatfooted participants compared to all asymptomatic groups. SIGNIFICANCE:The results suggest that foot motion in the transverse plane is closely associated with the presence of symptoms in flat feet and that this is accompanied by changes in the kinematics of the ankle, knee, and hip. 10.1016/j.gaitpost.2018.10.015
The influence of myofascial release on pain and selected indicators of flat foot in adults: a controlled randomized trial. Scientific reports Flat foot pain is a common complaint that requires therapeutic intervention. Currently, myofascial release techniques are often used in the therapy of musculoskeletal disorders. A group of 60 people suffering from flat feet with associated pain. Patients were assigned to four groups (15 people each): MF-myofascial release, E-the exercise program, MFE-myofascial release and the exercise program, C-no intervention. The rehabilitation program lasted 4 weeks. The NRS scale was used to examine pain intensity and FreeMed ground reaction force platform was used to examine selected static and dynamic foot indicators. Statistically significant pain reduction was obtained in all research. A static test of foot load distribution produced statistically significant changes only for selected indicators. In the dynamic test, statistically significant changes were observed for selected indicators, only in the groups subjected to therapeutic intervention. Most such changes were observed in the MF group. In the dynamic test which assessed the support phase of the foot, statistically significant changes were observed only for selected subphases. Most such changes were observed in the MFE group. Both exercise and exercise combined with myofascial release techniques, and especially myofascial release techniques alone, significantly reduce pain in a flat foot. This study shows a limited influence of both exercises and myofascial release techniques on selected static and dynamic indicators of a flat foot. 10.1038/s41598-022-05401-w
Effects of Artificial Texture Insoles and Foot Arches on Improving Arch Collapse in Flat Feet. Wang Yao-Te,Chen Jong-Chen,Lin Ying-Sheng Sensors (Basel, Switzerland) The arches of the foot play a vital role in cushioning the impact and pressure generated from ground reaction forces due to body weight. Owing to a lack of normal human arch structure, people diagnosed as having flat feet often have discomfort in the soles of their feet. The results may not only cause inappropriate foot pressure distribution on the sole but also further cause foot injuries. This study heavily relies on a homemade foot pressure sensing device equipped with textured insoles of different heights and artificial arches. This was to explore the extent to which the pressure distribution of the foot in people with flat feet could be improved. A further comparison was made of the effects of using the textured insoles with different heights on two different groups of people diagnosed with flat and normal feet respectively. Sixty-five undergraduate and postgraduate volunteers were invited to receive the ink footprint test for measuring their degrees of arch index. Nine of these 65 had 2 flat feet, 3 had a left flat foot, 5 had a right flat foot, and 48 had 2 normal feet. To ensure the same number of subjects in both the control and the experimental groups, 9 of the 48 subjects who had normal feet were randomly selected. In total, 26 subjects (Male: 25, Female: 1; Age: 22 ± 1 years; height: 173.6 ± 2.5 cm; body mass: 68.3 ± 5.4 kg; BMI: 22.6 ± 1.2) were invited to participate in this foot pressure sensing insoles study. The experimental results showed that the use of textured insoles designed with different heights could not effectively improve the plantar pressure distribution and body stability in subjects with flat feet. Conversely, the use of an artificial arch effectively improved the excessive peak in pressure and poor body stability, and alleviated the problem of plantar collapse for patients with flat feet, especially in the inner part of their hallux and forefoot. 10.3390/s20133667
Analysis of skeletal characteristics of flat feet using three-dimensional foot scanner and digital footprint. Biomedical engineering online BACKGROUND:Flat feet increase the risk of knee osteoarthritis and contribute to frailty, which may lead to worse life prognoses. The influence of the foot skeletal structure on flat feet is not yet entirely understood. Footprints are often used to evaluate feet. However, footprint-based measurements do not reflect the underlying structures of feet and are easily confounded by soft tissue. Three-dimensional evaluation of the foot shape can reveal the characteristics of flat feet. Therefore, foot shape evaluations have garnered increasing research interest. This study aimed to determine the correlation between the three-dimensional (3D) features of the foot and the measurement results of footprint and to predict the evaluation results of flat feet from the footprint based on the 3D features. Finally, the three-dimensional characteristics of flat feet, which cannot be revealed by footprint, were determined. METHODS:A total of 403 individuals (40-89 years) participated in this study. The proposed system was developed to identify seven skeletal features that were expected to be associated with flat feet. The loads on the soles of the feet were measured in a static standing position and with a digital footprint device. Specifically, two footprint indices were calculated: the Chippaux-Smirak index (CSI) and the Staheli index (SI). In the analysis, comparisons between male and female measurement variables were performed using the Student's t test. The relationships between the 3D foot features and footprint index parameters were determined by employing the Pearson correlation coefficient. Multiple linear regression was utilized to identify 3D foot features that were strongly associated with the CSI and SI. Foot features identified as significant in the multivariate regression analysis were compared based on a one-way analysis of variance (ANOVA) with Tukey's post hoc test. RESULTS:The CSI and SI were highly correlated with the instep height (IH) and navicular height (NH) of the 3D foot scanning system and were also derived from multiple regression analysis. In addition to the NH and IH, the indicators of the forefoot, transverse arch width, and transverse arch height were considered. In the flat foot group with CSI values above 62.7%, NH was 13.5% (p < 0.001) for males and 14.9% (p = 0.01) for females, and the axis of the bone distance was 5.3% (p = 0.05) for males and 4.9% (p = 0.10) for females. In particular, for CSI values above 62.7% and NH values below 13%, the axis of the bone distance was large and the foot skeleton was deformed. CONCLUSIONS:Decreased navicular bone height could be evaluated with the 3D foot scanning system even when flat feet were not detected from the footprint. The results indicate that the use of quantitative indices for 3D foot measurements is important when evaluating the flattening of the foot. Trial registration number UMIN000037694. Name of the registry: University Hospital Medical Information Network Registry. Date of registration: August 15, 2019. 10.1186/s12938-022-01021-7
Foot Orthoses for Treating Flat Feet in Children. American family physician
Adult flatfoot. Toullec E Orthopaedics & traumatology, surgery & research : OTSR Adult flatfoot is defined as a flattening of the medial arch of the foot in weight-bearing and lack of a propulsive gait. The 3 lesion levels are the talonavicular, tibiotarsal and midfoot joints. The subtalar joint is damaged by the consequent rotational defects. Clinical examination determines deformity and reducibility, and assesses any posterior tibialis muscle deficit, the posterior tibialis tendon and spring ligament being frequently subject to degenerative lesions. Radiographic examination in 3 incidences in weight-bearing is essential, to determine the principal level of deformity. Tendon (posterior tibialis tendon) and ligamentous lesions (spring ligament and interosseous ligament) are analyzed on MRI or ultrasound. In fixed deformities, CT explores for arthritic evolution or specific etiologies. 3D CT reconstruction can analyze bone and joint morphology and contribute to the planning of any osteotomy. Medical management associates insoles and physiotherapy. Acute painful flatfoot requires strict cast immobilization. Surgical treatment associates numerous combinations of procedures, currently under assessment for supple flatfoot: for the hindfoot: medial slide calcaneal osteotomy, calcaneal lengthening osteotomy, or arthroereisis; for the midfoot: arthrodesis on one or several rays, or first cuneiform or first metatarsal osteotomy; for the ankle: medial collateral ligament repair with tendon transfer. Fixed deformities require arthrodesis of one or several joint-lines in the hindfoot; for the ankle, total replacement after realignment of the foot, or tibiotalocalcaneal fusion or ankle and hindfoot fusion; and, for the midfoot, cuneonavicular or cuneometatarsal fusion. Tendinous procedures are often associated. Specific etiologies may need individualized procedures. In conclusion, adult flatfoot tends to be diagnosed and managed too late, with consequent impact on the ankle, the management of which is complex and poorly codified. 10.1016/j.otsr.2014.07.030
Pediatric Pes Planus: A State-of-the-Art Review. Carr James B,Yang Scott,Lather Leigh Ann Pediatrics Flatfoot (pes planus) is common in infants and children and often resolves by adolescence. Thus, flatfoot is described as physiologic because it is usually flexible, painless, and of no functional consequence. In rare instances, flatfoot can become painful or rigid, which may be a sign of underlying foot pathology, including arthritis or tarsal coalition. Despite its prevalence, there is no standard definition for pediatric flatfoot. Furthermore, there are no large, prospective studies that compare the natural history of idiopathic, flexible flat feet throughout development in response to various treatments. The available literature does not elucidate which patients are at risk for developing pain and disability as young adults. Current evidence suggests that it is safe and appropriate to simply observe an asymptomatic child with flat feet. Painful flexible flatfoot may benefit from orthopedic intervention, such as physical therapy, bracing, or even a surgical procedure. Orthotics, although generally unproven to alter the course of flexible flatfoot, may provide relief of pain when present. Surgical procedures include Achilles tendon lengthening, bone-cutting procedures that rearrange the alignment of the foot (osteotomies), fusion of joints (arthrodesis), or insertion of a silicone or metal cap into the sinus tarsi to establish a medial foot arch (arthroereisis). It is important for a general pediatrician to know when a referral to an orthopedic specialist is indicated and which treatments may be offered to the patient. Updated awareness of the current evidence regarding pediatric flatfoot helps the provider confidently and appropriately counsel patients and families. 10.1542/peds.2015-1230
The typically developing paediatric foot: how flat should it be? A systematic review. Journal of foot and ankle research BACKGROUND:All typically developing children are born with flexible flat feet, progressively developing a medial longitudinal arch during the first decade of their lives. Whilst the child's foot is expected to be flat, there is currently no consensus as to this foot should be. Furthermore, whilst feet are observed to decrease in flatness with increasing age, it is not known they should be at each age increment. The objective of this systematic review is to define the postural characteristics of the 'typically' developing paediatric foot. METHODS:The PRISMA protocol was applied to compare all data currently published describing the typical development of the paediatric foot. The Epidemiological Appraisal Instrument (EAI) was used to assess the risk of bias of the included studies. RESULTS:Thirty four epidemiological papers pertaining to the development of the paediatric foot were graphically compared. Sixteen different foot posture assessments were identified of which footprint based measures were the most reported outcome. CONCLUSION:Firstly, the use of the term in relation to foot posture is misleading in the categorisation of the paediatric foot, as indeed a flat foot posture is a normal finding at specific ages. Secondly, the foot posture of the developing child is indeed age dependent and has been shown to change over time. Thirdly, no firm conclusion could be reached as to which age the foot posture of children ceases to develop further, as no two foot measures are comparable, therefore future research needs to consider the development of consensus recommendations as to the measurement of the paediatric foot, using valid and reliable assessment tools. 10.1186/s13047-017-0218-1
Pathology and management of flexible flat foot in children. Ueki Yoshino,Sakuma Eisuke,Wada Ikuo Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association We describe the pathology and treatment of flexible flat foot in children. The flexible flat foot is seen in the overly flexible foot and usually involves hypermobility of the subtalar joint. It typically occurs in childhood and may continue to adulthood. The arch develops spontaneously during the first decade of life in most children and comes within the normal range observed in adult feet. We prescribed orthoses for the treatment of flexible flat foot patients. Lateral weight-bearing radiographs and ultrasonography were helpful for the evaluation of the flat foot. Bleck recommended the UCBL shoe insert in cases of flexible flat foot if the standing or lateral rentgenogram demonstrates a talar plantar flexion angle (TPF) of 45° or greater. Bordelon suggested that cases of flexible flat foot should be treated if the standing or lateral roentgenogram demonstrates a Meary's talo-1st metatarsal angle (T1-MTA) of -15°or greater. However, the radiograph of a young child's foot poses some difficulties in making an accurate evaluation, because of the radiolucent cartilage zone. In this situation, a sagittal image obtained by ultrasonography has proved to be a powerful aid to evaluate the type of the flat foot. We classified the flat foot into three types: talo-navicular sag (T-N sag), naviculo-cuneiform sag (NC sag) and talo-navicular and naviculo-cuneiform sag (Mixed sag) following the criteria of Tachdjian. We recommended the NC sag and Mixed sag groups to be treated by using orthoses, while we kept a status of watchful waiting for the T-N sag group. However, we should consider the increasing complaints of children and their parents during the orthotic treatment. A through discussion between the parents of patients and the pediatric orthopedic doctors is necessary before orthotic treatment is started. 10.1016/j.jos.2018.09.018
Association of bilateral flat feet with knee pain and disability in patients with knee osteoarthritis: A cross-sectional study. Iijima Hirotaka,Ohi Hiroshi,Isho Takuya,Aoyama Tomoki,Fukutani Naoto,Kaneda Eishi,Ohi Kazuko,Abe Kaoru,Kuroki Hiroshi,Matsuda Shuichi Journal of orthopaedic research : official publication of the Orthopaedic Research Society This cross-sectional study examined the relationship of flat feet with knee pain, disability, and physical performance in patients with knee osteoarthritis (OA). Orthopedic clinic participants (n = 95; age 61-91 years; 68.4% women) with Kellgren-Lawrence (K/L) grade ≥1 in the medial compartment underwent evaluation of navicular height and foot length for flat feet. Knee pain intensity, disability, and physical performance were evaluated using the Japanese Knee Osteoarthritis Measure, 10-m walk, timed up and go, and five-repetition chair stand tests. Of the 95 enrolled patients, 24 (25.3%) had bilateral flat feet, and significantly higher knee pain compared to patients with no flat feet (11.3 ± 8.23 points vs. 6.58 ± 6.37 points; p = 0.043). A ordinal logistic regression analysis showed that bilateral flat feet were significantly associated with increased knee pain (proportional odds ratio: 5.48, 95% confidence interval: 1.96, 15.3; p = 0.001) compared with no flat feet, adjusted for age, sex, body mass index, and tibiofemoral joint K/L grade, which is consistent across various different cutoffs of the definition of flat feet. Physical performance was similar between patients with and without bilateral flat feet. The presence of unilateral flat feet was not significantly associated with any outcome measures. These findings indicate that bilateral, but not unilateral, flat feet are associated with worse knee pain. A prospective study investigating a causal relationship between bilateral flat feet posture and knee pain as well as disability would be of particular interest to verify the potential adverse effect of altered foot posture. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2490-2498, 2017. 10.1002/jor.23565
The long-term use of foot orthoses affects walking kinematics and kinetics of children with flexible flat feet: A randomized controlled trial. Jafarnezhadgero AmirAli,Madadi-Shad Morteza,Alavi-Mehr Seyed Majid,Granacher Urs PloS one BACKGROUND:Due to inconclusive evidence on the effects of foot orthoses treatment on lower limb kinematics and kinetics in children, studies are needed that particularly evaluate the long-term use of foot orthoses on lower limb alignment during walking. Thus, the main objective of this study was to evaluate the effects of long-term treatment with arch support foot orthoses versus a sham condition on lower extremity kinematics and kinetics during walking in children with flexible flat feet. METHODS:Thirty boys aged 8-12 years with flexible flat feet participated in this study. While the experimental group (n = 15) used medial arch support foot orthoses during everyday activities over a period of four months, the control group (n = 15) received flat 2-mm-thick insoles (i.e., sham condition) for the same time period. Before and after the intervention period, walking kinematics and ground reaction forces were collected. RESULTS:Significant group by time interactions were observed during walking at preferred gait speed for maximum ankle eversion, maximum ankle internal rotation angle, minimum knee abduction angle, maximum knee abduction angle, maximum knee external rotation angle, maximum knee internal rotation angle, maximum hip extension angle, and maximum hip external rotation angle in favor of the foot orthoses group. In addition, statistically significant group by time interactions were detected for maximum posterior, and vertical ground reaction forces in favor of the foot orthoses group. CONCLUSIONS:The long-term use of arch support foot orthoses proved to be feasible and effective in boys with flexible flat feet to improve lower limb alignment during walking. 10.1371/journal.pone.0205187
Paediatric flexible flat foot: how are we measuring it and are we getting it right? A systematic review. Journal of foot and ankle research BACKGROUND:Flexible flat foot is a normal observation in typically developing children, however, some children with flat feet present with pain and impaired lower limb function. The challenge for health professionals is to identify when foot posture is outside of expected findings and may warrant intervention. Diagnoses of flexible flat foot is often based on radiographic or clinical measures, yet the validity and reliability of these measures for a paediatric population is not clearly understood. The aim of this systematic review was to investigate how paediatric foot posture is defined and measured within the literature, and if the psychometric properties of these measures support any given diagnoses. METHODS:Electronic databases (MEDLINE, CINAHL, EMBASE, Cochrane, AMED, SportDiscus, PsycINFO, and Web of Science) were systematically searched in January 2017 for empirical studies where participants had diagnosed flexible flat foot and were aged 18 years or younger. Outcomes of interest were the foot posture measures and definitions used. Further articles were sought where cited in relation to the psychometric properties of the measures used. RESULTS:Of the 1101 unique records identified by the searches, 27 studies met the inclusion criteria involving 20 foot posture measures and 40 definitions of paediatric flexible flat foot. A further 18 citations were sought in relation to the psychometric properties of these measures. Three measures were deemed valid and reliable, the FPI-6 > + 6 for children aged three to 15 years, a Staheli arch index of > 1.07 for children aged three to six and ≥ 1.28 for children six to nine, and a Chippaux-Smirak index of > 62.7% in three to seven year olds, > 59% in six to nine year olds and ≥ 40% for children aged nine to 16 years. No further measures were found to be valid for the paediatric population. CONCLUSION:No universally accepted criteria for diagnosing paediatric flat foot was found within existing literature, and psychometric data for foot posture measures and definitions used was limited. The outcomes of this review indicate that the FPI - 6, Staheli arch index or Chippaux-Smirak index should be the preferred method of paediatric foot posture measurement in future research. 10.1186/s13047-018-0264-3
A Cochrane review of the evidence for non-surgical interventions for flexible pediatric flat feet. Evans A M,Rome K European journal of physical and rehabilitation medicine The pediatric flat foot is a frequent presentation in clinical practice, a common concern to parents and continues to be debated within professional ranks. As an entity, it is confused by varied classifications, the notion of well-intended prevention and unsubstantiated, if common, treatment. The available prevalence estimates are all limited by variable sampling, assessment measures and age groups and hence result in disparate findings (0.6-77.9%). Consistently, flat foot has been found to normally reduce with age. The normal findings of flat foot versus children's age estimates that approximately 45% of preschool children, and 15% of older children (average age 10 years) have flat feet. Few flexible flat feet have been found to be symptomatic. Joint hypermobility and increased weight or obesity may increase flat foot prevalence, independently of age. Most attempts at classification of flat foot morphology include the arch, heel position and foot flexibility. Usual assessment methods are footprint measures, X-rays and visual (scaled) observations. There is no standardized framework from which to evaluate the pediatric flat foot. The pediatric flat foot is often unnecessarily treated, being ill-defined and of uncertain prognosis. Contemporary management of the pediatric flat foot is directed algorithmically within this review, according to pain, age, flexibility; considering gender, weight, and joint hypermobility. When foot orthoses are indicated, inexpensive generic appliances will usually suffice. Customised foot orthoses should be reserved for children with foot pain and arthritis, for unusual morphology, or unresponsive cases. Surgery is rarely indicated for pediatric flat foot (unless rigid) and only at the failure of thorough conservative management. The assessment of the pediatric flatfoot needs to be considered with reference to the epidemiological findings, where there is consensus that pediatric flexible flat foot reduces with age and that most children are asymptomatic. Globally, there is need for a standard by which the pediatric flat foot is assessed classified and managed. Until then, assessment should utilize the available evidence-based management model, the p-FFP Future research needs to evaluate the pediatric flat foot from representative samples, of healthy and known disease-group children prospectively, and using validated assessment instruments. The preliminary findings of the benefits of foot exercises, and discrete investigation into the effects of shoes and footwear use are also warranted.
Foot orthoses for treating paediatric flat feet. The Cochrane database of systematic reviews BACKGROUND:Paediatric flat feet are a common presentation in primary care; reported prevalence approximates 15%. A minority of flat feet can hurt and limit gait. There is no optimal strategy, nor consensus, for using foot orthoses (FOs) to treat paediatric flat feet. OBJECTIVES:To assess the benefits and harms of foot orthoses for treating paediatric flat feet. SEARCH METHODS:We searched CENTRAL, MEDLINE, and Embase to 01 September 2021, and two clinical trials registers on 07 August 2020. SELECTION CRITERIA:We identified all randomised controlled trials (RCTs) of FOs as an intervention for paediatric flat feet. The outcomes included in this review were pain, function, quality of life, treatment success, and adverse events. Intended comparisons were: any FOs versus sham, any FOs versus shoes, customised FOs (CFOs) versus prefabricated FOs (PFOs). DATA COLLECTION AND ANALYSIS:We followed standard methods recommended by Cochrane. MAIN RESULTS:We included 16 trials with 1058 children, aged 11 months to 19 years, with flexible flat feet. Distinct flat foot presentations included asymptomatic, juvenile idiopathic arthritis (JIA), symptomatic and developmental co-ordination disorder (DCD). The trial interventions were FOs, footwear, foot and rehabilitative exercises, and neuromuscular electrical stimulation (NMES). Due to heterogeneity, we did not pool the data. Most trials had potential for selection, performance, detection, and selective reporting bias. No trial blinded participants. We present the results separately for asymptomatic (healthy children) and symptomatic (children with JIA) flat feet. The certainty of evidence was very low to low, downgraded for bias, imprecision, and indirectness. Three comparisons were evaluated across trials: CFO versus shoes; PFO versus shoes; CFO versus PFO. Asymptomatic flat feet 1. CFOs versus shoes (1 trial, 106 participants): low-quality evidence showed that CFOs result in little or no difference in the proportion without pain (10-point visual analogue scale (VAS)) at one year (risk ratio (RR) 0.85, 95% confidence interval (CI) 0.67 to 1.07); absolute decrease (11.8%, 95% CI 4.7% fewer to 15.8% more); or on withdrawals due to adverse events (RR 1.05, 95% CI 0.94 to 1.19); absolute effect (3.4% more, 95% CI 4.1% fewer to 13.1% more). 2. PFOs versus shoes (1 trial, 106 participants): low to very-low quality evidence showed that PFOs result in little or no difference in the proportion without pain (10-point VAS) at one year (RR 0.94, 95% CI 0.76 to 1.16); absolute effect (4.7% fewer, 95% CI 18.9% fewer to 12.6% more); or on withdrawals due to adverse events (RR 0.99, 95% CI 0.79 to 1.23). 3. CFOs versus PFOs (1 trial, 108 participants): low-quality evidence found no difference in the proportion without pain at one year (RR 0.93, 95% CI 0.73 to 1.18); absolute effect (7.4% fewer, 95% CI 22.2% fewer to 11.1% more); or on withdrawal due to adverse events (RR 1.00, 95% CI 0.90 to 1.12). Function and quality of life (QoL) were not assessed. Symptomatic (JIA) flat feet 1. CFOs versus shoes (1 trial, 28 participants, 3-month follow-up): very low-quality evidence showed little or no difference in pain (0 to 10 scale, 0 no pain) between groups (MD -1.5, 95% CI -2.78 to -0.22). Low-quality evidence showed improvements in function with CFOs (Foot Function Index - FFI disability, 0 to 100, 0 best function; MD -18.55, 95% CI -34.42 to -2.68), child-rated QoL (PedsQL, 0 to 100, 100 best quality; MD 12.1, 95% CI -1.6 to 25.8) and parent-rated QoL (PedsQL MD 9, 95% CI -4.1 to 22.1) and little or no difference between groups in treatment success (timed walking; MD -1.33 seconds, 95% CI -2.77 to 0.11), or withdrawals due to adverse events (RR 0.58, 95% CI 0.11 to 2.94); absolute difference (9.7% fewer, 20.5 % fewer to 44.8% more). 2. PFOs versus shoes (1 trial, 25 participants, 3-month follow-up): very low-quality evidence showed little or no difference in pain between groups (MD 0.02, 95% CI -1.94 to 1.98). Low-quality evidence showed no difference between groups in function (FFI-disability MD -4.17, 95% CI -24.4 to 16.06), child-rated QoL (PedsQL MD -3.84, 95% CI -19 to 11.33), or parent-rated QoL (PedsQL MD -0.64, 95% CI -13.22 to 11.94). 3. CFOs versus PFOs (2 trials, 87 participants): low-quality evidence showed little or no difference between groups in pain (0 to 10 scale, 0 no pain) at 3 months (MD -1.48, 95% CI -3.23 to 0.26), function (FFI-disability MD -7.28, 95% CI -15.47 to 0.92), child-rated QoL (PedsQL MD 8.6, 95% CI -3.9 to 21.2), or parent-rated QoL (PedsQL MD 2.9, 95% CI -11 to 16.8). AUTHORS' CONCLUSIONS:Low to very low-certainty evidence shows that the effect of CFOs (high cost) or PFOs (low cost) versus shoes, and CFOs versus PFOs on pain, function and HRQoL is uncertain. This is pertinent for clinical practice, given the economic disparity between CFOs and PFOs. FOs may improve pain and function, versus shoes in children with JIA, with minimal delineation between costly CFOs and generic PFOs. This review updates that from 2010, confirming that in the absence of pain, the use of high-cost CFOs for healthy children with flexible flat feet has no supporting evidence, and draws very limited conclusions about FOs for treating paediatric flat feet. The availability of normative and prospective foot development data, dismisses most flat foot concerns, and negates continued attention to this topic. Attention should be re-directed to relevant paediatric foot conditions, which cause pain, limit function, or reduce quality of life. The agenda for researching asymptomatic flat feet in healthy children must be relegated to history, and replaced by a targeted research rationale, addressing children with indisputable foot pathology from discrete diagnoses, namely JIA, cerebral palsy, congenital talipes equino varus, trisomy 21 and Charcot Marie Tooth. Whether research resources should continue to be wasted on studying flat feet in healthy children that do not hurt, is questionable. Future updates of this review will address only relevant paediatric foot conditions. 10.1002/14651858.CD006311.pub4
The contribution of the ligaments in progressive collapsing foot deformity: A comprehensive computational study. Journal of orthopaedic research : official publication of the Orthopaedic Research Society The contribution of each of the ligaments in preventing the arch loss, hindfoot valgus, and forefoot abduction seen in progressive collapsing foot deformity (PCFD) has not been well characterized. An improved understanding of the individual ligament contributions to the deformity would aid in selecting among available treatments, optimizing current surgical techniques, and developing new ones. In this study, we evaluated the contribution of each ligament to the maintenance of foot alignment using a finite element model of the foot reconstructed from computed tomography scan images. The collapsed foot was modeled by simulating the failure of all the ligaments involved in PCFD. The ligaments were removed one at a time to determine the impact of each ligament on foot alignment, and then restored one at a time to simulate isolated reconstruction. Our findings show that the failure of any one ligament did not immediately lead to deformity, but that combined failure of only a few (the plantar fascia, long plantar, short plantar, deltoid, and spring ligaments) could lead to significant deformity. The plantar fascia, deltoid, and spring ligaments were primarily responsible for the prevention of arch collapse, hindfoot valgus, and forefoot abduction, respectively. Moreover, to produce deformity, a considerable amount of attenuation in the spring, tibiocalcaneal, interosseous talocalcaneal, plantar naviculocuneiform, and first plantar tarsometatarsal ligaments, but only a small amount in the plantar fascia, long plantar, and short plantar ligaments was needed. The results of this study suggest that the ability of a ligament to prevent deformity may not correlate with its attenuation in a collapsed foot. 10.1002/jor.25244