ARCHES OF FOOT

ANATOMY OF THE ARCHES OF

FOOT
A) Two longitudinal arches
– Medial longitudinal arch
– Lateral longitudinal arch
B) Transverse arch
• Anterior transverse arch
• Posterior transverse arch
 USES OF THE ARCHED FOOT

 Supports body weight in upright posture

 Acts as a lever to propel the body forwards in walking,

running and jumping
 Acts as a shock absorber

 Concavity of the arches protects the soft tissues of the sole

against pressure
 Medial longitudinal arch
• Higher than lateral
• Composed of – Calcaneous
- Talus
- Navicular
- 3 cuneiform
- 3 metatarsals
• Talar head is key stone of this arch
• Tibialis anterior attached to – 1st metatarsal,medial cuneiform –
strength for this arch.

• Peroneus longus tendon – pass laterally to this arch

providing support
 Lateral longitudinal Arch
• Flatter than medial longitudinal arch.
• Rests on the ground during standing.
• It is made up of – calcaneous, cuboid, 2
lateral metatarsals.
 Transverse arch
• Runs from side to side
• It is formed by – cuboid,
cuneiforms, bases of
metatarsals
• Medial and lateral parts
of longitudinal arch act as
pillars
• Tendons of
fibularis longus and
tibialis posterior
 Integrity of bony arches

• Maintained by passive factors and dynamic

supports
 Passive factors

• Shape of the united bones

• Four successive layers of fibrous
tissue – bowstring the longitudinal
arch
– Plantar aponeurosis
– Long plantar ligament
– Plantar calcaneocuboid (short
plantar) ligament
– Plantar calcaneonavicular
(spring) ligament
 Dynamic supports

• Active bracing action of intrinsic muscles of foot

• Active and tonic contraction of muscles with

long tendons extending in to foot

– Flexor hallusis and digitorum longus – longitudinal

arch

– Fibularis longus and tibialis posterior – transverse

arch
 MECHANISM OF ARCH SUPPORT
SHAPE OF BONES

• Bones are wedge-shaped with the thin edge lying inferiorly

• This applies particularly to the bone occupying the center o

the arch“keystone”
 MECHANISM OF ARCH SUPPORT
SUSPENDING THE ARCH FROM
ABOVE
• Medial longtitudinal arch: Tibialis anterior, Tibialis
posterior, medial ligament of ankle joint
• Lateral longtitudinal arch: Peroneus longus, Peroneus
brevis
• Transverse arch: Peroneus longus
 MECHANISM OF ARCH SUPPORT
SUSPENDING THE ARCH FROM ABOVE
PES CAVUS
Synonyms for Cavus Foot

• Anterior Equinus • Schaffer Foot

• Pes Cavo Varus • Lotus Flower Foot

• Contracted Foot • Bolt Foot

• Talipes (Pes) Arcuatus • Claw Foot

• Talipes Plantaris • Vault Foot

• Hollow Foot
 Definition

• Cavus is an acquired or congenital

deformity of the foot ,characterized by
excessive high longitudinal plantar arch
combined with clawing of the toes .
 Etiology

Neurological Causes
• Charcot Marie Tooth disease

• Friedrich’s Ataxia

• Roussy-Levy syndrome

• Poliomyelitis

• Cerebral Palsy
 Congenital
– Spina Bifida

– Talipes Equinovarus

– Myelodysplasia

– Clubfoot
Iatrogenic
– Post surgery or trauma

– Peroneal nerve injury

Infection
– Syphillis

– Poliomyelitis

Idiopathic
– Most common
 Development of the deformity
• The intrinsic musculature
normally flexes the
metatarsophalyngeal joint
and extends the
interphalyngeal joint.
• When the long flexor contracts on the straight digit it slings
up the heads of the metatarsals and prevents the drop of the
forefoot on the hind foot
• In the absence of lumbricals ,the long flexor pulls the toes
into flexion and no longer supports the metatarsal head.
• So the forefoot drops and the lax structures in the sole
contracts and forms claw foot.
• Dropping of fore foot on the hind foot followed by a
contracture of the plantar fascia and clawing of the
toes
 CLINICAL FEATURES
• High arch.
• Hyper extension of toes at
metatarso-phalyngeal joint
• Hyper flexion at the inter-
phalyngeal joints.
• Pronation and adduction of
the fore foot .
• Lengthened lateral border of
foot and shortened medal
border.
• Callosities beneath the
metatarsal heads
• A bony dorsum of mid-foot with
wrinkled skin folds on the
medial plantar aspect
 Radiographic findings –pes cavus
Standing weight bearing Antero –posterior and Lateral views
X Rays taken to
• Demonstrate the apex of the deformity

• Talo calcaneal ankle

• Calcaneal pitch

• Degree of plantar flexion of the great toe

• Asess the contribution of cavus by hind foot,midfoot and

fore foot
 DEGREES OF PES CAVUS
• 5 degrees
First degree pes cavus
• Child is clumsy with repeated falls
• Foot appears normal
• Deformity appears when foot is relaxed
• Child catches his toes against low objects such as edges
carpet.
• Mild extensor weakness
 Treatment of first degree pes cavus

• Daily manipulation –supinating fore foot and everting heel

• Anterior arch bar in shoes

• If not corrected then Girdle stone tendon transfer

operation.
• Through an incision on each toe
extending distally from metatarso-
phalyngeal joint .
• Long and short toe flexors are brought
to lateral aspect of proximal phalynx
and sutured to the extensor expansion.
 Second degree pes cavus
• Flexion of the fore foot

• Plantar fascia is felt to be tense and contracted

• Clawing of great toe .

• Great toe clawing can be corrected by upward pressure on

the ball of great toe.
 Treatment of second degree Pes cavus

• A shoe fitted with a metatarsal bar may give temporary

relief.
• Stiendlers Procedure : Plantar fascia release

• Jones Procedure:The Extensor hallucis longus tendon is

divided at its insertion and passed though the neck of first
metatarsal + Interphalyngeal joint fusion.
 Third degree pes cavus

• The arches of foot is markedly raised.

• All toes are clawed .

• Tendocalcaneus may begin to appear contracted.

• Painfull callosities are seen.

• Deformities are rigid and cannot be corrected by finger

pressure under Ist metatarsal head
 Treatment of third degree Pes cavus

• Stiendlers procedure +Muscle

sliding operation.
• Japas ‘ V‘osteotomy of tarsus : Apex of V
is proximal and highest point of cavus
• Dwayers Calcaneal Ostetomy
 Fourth degree pes cavus

• In addition to cavus and claw toes

• Adduction at tarsometatarsal joints resulting in varus

deformity.
• Rigid and painful foot

• Walking becomes painful and difficult.

 Fifth degree-pes cavus

• Seen on paralytic conditions.(poliomyelitis)

• Whole foot is contracted into rigid equino varus with high

arch.
• Tender callosities.

• The patient is very disabled .

 Treatment of fourth and fifth degree Pes cavus

• Dunns triple arthrodesis

• Lambrinudis arthrodesis

(triple arthrodesis :subtalar+calcneo cuboid

+talo navicular joint fusion)
• Cols Anterior tarsal wedge osteotomy
PES-PLANUS
 Synonyms

• Pes planovalgus

• Flat feet

• Fallen arches

• Pronation of feet
 Definition

• Absence of normal medial longitudinal arch

• Instep of the foot collapses and comes

in contact with the ground.
• In some individuals, this arch never
develops
 Other abnormalities

• Heel valgus
• Mild subluxation of subtalar joint(talus tilts medially and
plantarwards)

• Eversion of the calcaneus at the subtalar joint

• Lateral angulation of midtarsal joints (Talo Calcaneal

 ,Calcaneo Cuboid)

• Supination of forefeet
• Flat feet are a common condition.

• In infants and toddlers, the longitudinal arch is

not developed and flat feet are normal.
• The arch develops in childhood

• By adulthood (12-13yrs), most people

have developed normal arches
 Types

 Flexible Can be
 Rigid painless
Painful
 Types

• Flexible –on weight bearing it disappears

and on non weight bearing it reappears
• Rigid – acceptable medial longitudinal
arch does not seen even on non weight
bearing
• Flexible, painless is most common
 Etiology

Flexible
 Developmental – the most common
 Hypermobile (ligamentous hyperlaxity; Ehlers-Donlos, Marfans)
 Neurogenic( rare and usually cause the reverse-Pes Cavus)

Rigid
 Congenital (Tarsal coalition,Vertical talus)
 Aquired )inflammatory)
 SYMPTOMS

Deformity
• Foot pain ,ankle pain, leg pain

• Heel tilts away from the midline of the body more than
usual
• Abnormal shoe wear
 FLAT FEET CAN produce

• Tendonitis. posterior tibial tendon and it can either fail,

rupture, stretch or just hurt. This condition is called
POSTERIOR TIBIAL DYSFUNCTION (PTD OR TPD) .
• Arthritis.

• Plantar fasciitis

• Bunions & Hammertoes

• Corns and callosities

 Radiography

• Asymptomatic flatfoot radiological evaluation

unnecessary
• First Antero posterior and Lateral views of the foot
should be taken to evaluate severity of deformity
• Antero-posterior ankle to rule out valgus at the distal end of
tibia
• Special view - 45 degree eversion oblique for accessory
navicular bone
 Radiography
• AP standing view is to asses heel valgus ,
Talocalcaneal angle more than 35 degree is associated
with incresed heel valgus
• CT scan accurately defines anatomy of subtalar joint ,
allows surgical plannig if it is involved.
 Meary’s Angle

• Most common angle to

indicate flat foot
• Intersects at apex of the
deformity
• Meary’s angle - between long
axis of talus and long axis of
first metatarsal on a
standing lateral X ray
 Normal Meary's angle:long axis
of the talus should bisect the
navicular and first metatarsal

0 degrees – normal

0 – 15 degrees – mild

15 – 40 degrees – moderate

> 40 degrees – severe

The long axis of the talus is angled plantarward in relation to

the first metatarsal, consistent with pes planus
 Treatment

0-3 years old:

 No treatment unless very strong family hx of persistent
flatfeet
 Orthotic shoes with thomas heels ,medial heel wedges and
navicular pads
 Convince the parents.
 Treatment

3-9 years
• Conservative management

• No surgery

• Custom orthosis inserted with leather ,cork,

propylene .
 Treatment

• 10-14 yrs

• No symptom- No treatment

• Symptomatic – conservative
management initially
• Surgical
 Surgical treatment
Indications

1. pain

2. failure to respond to orthotic control

3.Ulceration or callus under the head of the plantiflexed talus

4.Excessive shoe wear

 Surgical treatment

• The surgeon , patient, and parents must be willing to

exchange loss of eversion and inversion of the foot
for relief of pain and disability .
 Surgical treatment

• Arthrodesis for relieving painful flat foot have been

most successful when the subtalar joint is
involved .
• Although midtarsal arthtrodesis without inclusion
of the subtalar joint has gained popularity
 Surgeries

• Durham flatfoot plasty

• Posterior calcaneal displacement osteotomy

• Anterior calcaneal lengthening –

distraction wedge osteotomy
• Triple atrhrodesis (triplane)
Durham plasty for pes planus
A, Incision.
B, Elevation of posterior
tibial tendon.
C, Elevation of osteo-periosteal
flap from proximal to distal.
D, Arthrodesis of navicular–first
cuneiform joint.
E, Extent of arthrodesis
resection through midfoot.
F, Internal fixation of navicular–

first cuneiform joint.

•

pull the posterior tibial tendon taut

into its prepared bed on the
plantar surface of the waist of the
navicular, and tie the suture
dorsally
 Calcaneal osteotomy (Dilwyn-
Evana,Mosca)
• Lengthening of lateral
column of the foot by
inserting a tibial bone graft
and calcaneocuboidal
fusion
 Posterior calcaneal displacement
osteotomy(koutsgiannis)

• Symptomatic patients with excessive heel valgus , a

calcaneal osteotomy is intended to displace the
posterior part of the calcaneum medially , to restore
normal Weight bearing alignment
 Triple Arthrodesis

Joints fused are:

• Subtalar joint

• Calcaneo cuboid joint

• Talo navicular joint

AGE
• Usually done after the age of 12

• Triple arthrodesis tend to have a high (50%) failure rate in

children under 10 years of age;
• contra-indicated in young children (less than 10-12 yrs)
because the procedure limits foot growth
 Complications

• Nonunion

• Degenerative joint disease

• Avascular necrosis

• Lateral instability

• Stiff foot
 Accessory navicular bone
• It is a most common accessory bone in the foot

• Listed as a cause of flat foot

 Pathoanatomy

• Abnormal insertion of Tibialis Posterior into

accessory navicular bone believe to cause the

flat foot
 Clinical presntation

• Often incidental, many patients are asymptomatic

• Pain

• Prominence of medial aspect of foot

• On attempted inversion of the foot against

resistance
, Tibialis posterior tendon is inserted into the
bump and this maneuver produces pain
 Radiography

• Special view - 45 degree eversion oblique for

accessory navicular bone
• Antero-Posterior view and Lateral weight
bearing views of the foot should be taken to
evaluate other deformities
 Radiological types

• TypeI–Small ossicle in the substance of Tibialis Posterior

tendon (os tibiale externum or naviculam secondorium )
• Type II –Triangular frangment larger than type I
connected to navicular bone by a cartilaginous
synchondrosis
• Type III – Cornuate navicular resulting from fusion of the
accessory navicular with main body of navicular
 Treatment

INITIAL TREATMENT –

Conservative- stretcing shoes, avoiding

activity that irritates foot

SURGICAL-

Kidners procedure
 Kidners procedure

• Excision of accessory navicular bone and rerouting of

Tibialis Posterior tendon into a more plantar position
• Parents should be informed before surgery that pain
may not be alleviated completely
 THANK YOU

“Our feet are no more alike than our

faces”