docWhat Happens to the Paediatric Flat Foot?
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What Happens to the Paediatric Flat Foot?
What Happens to the Paediatric Flat Foot? Peter J Briggs Freeman Hospital Newcastle upon Tyne We don’t know!! Population Studies • 2300 children aged 4 - 13 years • Shoe wearers • Non-shoe wearers Flat foot 8.6% Flat foot 2.8% • Risk factors – Closed in footwear – Ligamentous laxity Rao and Joseph, 1992 Population Studies • 1846 Adults - Age starting to use footwear • Before age 6 • Between 6 – 15 • Over 16 Flat foot 3.24% Flat foot 3.27% Flat foot 1.75% • Footwear influences the development of the child’s foot Sachithanandam and Joseph, 1995 Causes of Flatfoot • Congenital • Acquired – Tibialis Posterior Dysfunction – Arthritis – Trauma – Neuroarthropathy – Neuromuscular Disorders – Tumours Can we define a Flat Foot? • Visual inspection • Foot print analysis • Radiographs PICTURES HAVE BEEN REMOVED DUE TO PATIENT CONFIDENTIALITY • Forefoot abduction • Prominence of medial malleolus and talar head • Loss of arch height PICTURES HAVE BEEN REMOVED DUE TO PATIENT CONFIDENTIALITY • Loss of arch height • Prominence of talar head or navicular PICTURES HAVE BEEN REMOVED DUE TO PATIENT CONFIDENTIALITY • Heel pronation • “Too many toes” PICTURES HAVE BEEN REMOVED DUE TO PATIENT CONFIDENTIALITY PICTURES HAVE BEEN REMOVED DUE TO PATIENT CONFIDENTIALITY Bones of the Foot Talus Os Calcis (Calcaneum) Navicular Cuneiforms Metatarsals Phalanges Sesamoids Joints of the Foot Ankle Talonavicular Metatarsophalangeal MTP Subtalar Tarsometatarsal Ligaments Ligaments of the Foot Interosseous Ligament Spring Ligament Long and Short Plantar Ligaments Plantar Aponeurosis (Fascia) Ligaments • Plantar aponeurosis • Long and short plantar ligaments • Spring ligament 25% 10% 10% • Residual stiffness 63% Huang et al, 1993 Muscles and Tendons of the Foot Tibialis Posterior – Tib Post Flexor Hallucis Longus - FHL Foot Balance Foot Balance Tibialis Posterior Function Normal foot Flat foot Gray and Basmajian, 1968 WALKING: HEEL STRIKE Plantar-flexion of foot Eccentric contraction tibialis anterior Digital extensors stretched in front of the ankle PICTURES HAVE BEEN REMOVED DUE TO PATIENT CONFIDENTIALITY WALKING: HEEL STRIKE Toes pulled into dorsiflexion Plantar pad pulled distally Reflex contraction of tibialis posterior controlling heel pronation moment PICTURES HAVE BEEN REMOVED DUE TO PATIENT CONFIDENTIALITY FOREFOOT CONTACT Plantar pad contact progresses As each metatarsal ray becomes weight bearing it flattens PICTURES HAVE BEEN REMOVED DUE TO PATIENT CONFIDENTIALITY FOOT FLAT Plantar aponeurosis tightens Reversed windlass mechanism activated flexing the toes Plantar pad contact area increases PICTURES HAVE BEEN REMOVED DUE TO PATIENT CONFIDENTIALITY EARLY HEEL ELEVATION Gastroc-soleus contraction Tibialis posterior and peroneals contraction Body momentum Reversed windlass mechanism further enhanced PICTURES HAVE BEEN REMOVED DUE TO PATIENT CONFIDENTIALITY HIGH HEEL ELEVATION Concentration of loading under 1st three metatarsals Passive toe dorsiflexion causing arch elevation and heel supination Stabilisation of 1st metatarsal by plantar aponeurosis for push - off PICTURES HAVE BEEN REMOVED DUE TO PATIENT CONFIDENTIALITY HIGH HEEL ELEVATION Changing shape of the foot driven by plantar aponeurosis and tibialis posterior Heel, ankle, talonavicular joint and forefoot centre of load kept in sagittal plane Midtarsal stability from strong plantar ligaments with tibialis posterior and peroneal control PICTURES HAVE BEEN REMOVED DUE TO PATIENT CONFIDENTIALITY LIFT OFF Plantar pad loses ground contact Energy stored in stretched plantar aponeurosis released flexing the toes at toe-off Assisted by digital flexors PICTURES HAVE BEEN REMOVED DUE TO PATIENT CONFIDENTIALITY • Impairment of Plantar Aponeurosis Function • Forefoot abduction • Hallux deformities common PICTURES HAVE BEEN REMOVED DUE TO PATIENT CONFIDENTIALITY Flat Foot in the Adult • Many asymptomatic • Medial ankle pain • Shin pain • Knee pain • Sport PICTURES HAVE BEEN REMOVED DUE TO PATIENT CONFIDENTIALITY Orthoses Equinus Contracture • Achilles contracture will overcome any orthotic attempt to control heel rotation Tibialis Posterior Failure Tibialis Posterior Failure • Tendon failure • Ligament failure • Age 50+ PICTURES HAVE BEEN REMOVED DUE TO PATIENT CONFIDENTIALITY Adult Flat Foot • Risk Factors for Clinical Problems – Ligamentous laxity – Obesity – Rotational deformities – Pathological tibia varum – Equinus – Activity level – Shoe style Napolitano et al, 2000 Happy New Year!
