Key Insights On Conservative Care For Adult Flatfoot

Patrick DeHeer, DPM, FACFAS, FASPS, and Aaron Warnock, DPM

   One must examine the patient while standing and the exam should begin with an evaluation of the legs, ankles and feet. Clinicians should have the patient stand facing directly at them with feet parallel and shoulder width apart. Evaluate the knee and leg for deviation in the frontal and transverse planes, genu varum and hyperextension of the knee. Evaluate the ankle for asymmetrical swelling and proper alignment.

   Then evaluate the foot for a pes planus foot type. The hallmark findings of a pes planus foot type are collapse of the longitudinal medial arch, a prominent talar head medially and abduction of the forefoot on the rearfoot. With the patient still facing forward, employ the Hubscher maneuver or toe test of Jack, and the trunk test to evaluate if the deformity is flexible or not.

   Observe the patient while walking to look for any gait disturbance, such as an apropulsive gait and an early heel rise. The clinician should then have the patient turn 180 degrees with the feet still parallel and shoulder width apart. Pes planus will present itself once again as a collapsed arch, a prominent talar head medially, a valgus attitude of the rearfoot to the leg and a positive too many toes sign. A double heel rise test in conjunction with a single leg heel rise can help one evaluate the posterior tibialis tendon function and deformity reducibility. Dysfunction of the posterior tibialis tendon will be apparent if there is asymmetrical or incomplete inversion of the hindfoot during this maneuver, and the inability to perform the single leg heel rise.

   Lastly, we evaluate the extent of the deformity by using weightbearing plain film X-rays, including lateral, dorsal-plantar, lateral oblique views of the foot and an ankle anterior-posterior view, to evaluate for ankle valgus. Advanced imaging studies, such as computed tomography (CT), ultrasound and magnetic resonance imaging (MRI), are not warranted if one can make the diagnosis clinically and on plain films. Reserve these studies for instances when the diagnosis of posterior tibial tendon dysfunction has come into question or if information from these studies will affect management.

A Guide To Staging Flatfoot

There is an overwhelming amount of literature stating that PTTD is the most common cause of an adult-acquired flatfoot. It is a good practice to classify your flatfoot patients.
We use the Johnson and Strom staging system in our clinic.4 Sizensky and coworkers noted that Johnson and Strom’s 1989 staging system for PTTD is based on the clinical presentation and severity of deformity as the disease progresses along a continuum.5

   Stage I is characterized by tenosynovitis of the posterior tibial tendon without tendon elongation or clinical deformity.4 A patient in this stage is able to perform a single-limb and double-limb heel rise. Stage II is marked by tendon elongation, incompetence and degeneration as well as a flexible pes planovalgus deformity. Stage II patients frequently are not strong enough to perform a single-limb heel rise although these patients typically demonstrate heel inversion on double-limb heel rise, which indicates a supple deformity. Patients with stage III have a fixed, irreducible flatfoot deformity and cannot perform a single-limb or double-limb heel rise.

   Myerson modified this classification and proposed a stage IV, a progression of stage III disease characterized by deltoid insufficiency and valgus ankle instability.6 Researchers have proposed a stage IIb to describe a stage II deformity with residual forefoot supination (varus) of more than 10 degrees when the hindfoot has been reduced to a neutral position.7

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