Learning objective 1 and 4
History taking:
A 70 year-old female patient had chronic pain in her left ankle since 3 years ago. Pain is aggravated
by long walking or after heavy activity. Progressive loss of foot arch height.
No known comorbidity.
Physical examination: General look well.
Lower limb:
Foot and ankle: pes planus (collapse of the medial longitudinal arch), “too many toes” sign.
Tenderness over posterior and tip of medial malleolus. Full active and passive range of motion in
ankle and hindfoot, resisted inversion.
Unable to perform single-limb heel rise.
Nonsurgical management in the last 6 month has failed to provide symptomatic relief.
Differential diagnosis: acquired adult right flat foot due to tibialis posterior insufficiency.
 Pes planus secondary to
o midfoot pathology (osteoarthritis or chronic Lisfranc injury)
o incompetence of the spring ligament (primary static stabilizer of the talonavicular
joint) in the absence of PTT pathology
Plan of diagnosis:
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
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Radiographs
o recommended views
 weight bearing AP and lateral foot
 ankle mortise
o findings
 AP foot
 increased talonavicular uncoverage
 increased talo-first metatarsal angle (Simmon angle)
 seen in stages II-IV
 weight bearing lateral foot
 increased talo-first metatarsal angle (Meary angle)
 angles >4° indicate pes planus
 seen in stages II-IV
 ankle mortise
 talar tilt due to deltoid insufficiency
MRI
o Findings variable amounts of tendon degeneration and arthritic changes in the
talonavicular, subtalar, and tibiotalar joints
Ultrasound: increasing role in the evaluation of pathology within the PTT
Weight bearing lateral radiograph of the foot shows longitudinal arch collapse
MRI: Sagital STIR image shows a tibialis posterior insufficiency and tenosynovitis.
Treatment plan:
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Nonoperative
o immobilization in walking cast/boot for 3-4 months
 indications
 first line of treatment in stage I disease
o custom-molded in-shoe orthosis
 indications
 stage I patients after a period of immobilization
 stage II patients
 technique
 medial heel lift and longitudinal arch support
 medial forefoot post indicated if fixed forefoot varus is present
 UCBL with medial posting
o ankle foot orthosis
 indications
 stage II, III, and IV patients who are not operative candidates, are sedentary
and low demand (age > 60-70)
 technique
 AFO family of braces (Arizona, molded, articulating)
 AFO found to be most effective
 want medial orthotic post to support valgus collapse
 Arizona brace is a molded leather gauntlet that provides stability
to the tibiotalar joint, hindfoot, and longitudinal arch
Operative
o tenosynovectomy
 indications
 indicated in stage I disease if immobilization fails
o FDL transfer, calcaneal osteotomy, TAL, +/- forefoot correction osteotomy, +/- spring
ligament repair, +/- lateral column lengthening, +/- PTT debridement
 indications
 stage II disease

o
o
o
contraindications
 hypermobility
 neuromuscular conditions
 severe subtalar arthritis
 obesity (relative)
 age >60-70 (relative)
triple arthrodesis and TAL
 indications
 stage III disease
 stage II disease with severe subtalar arthritis
triple arthrodesis and TAL + deltoid ligament reconstruction
 indications
 stage IV disease with passively correctable ankle valgus
tibiotalocalcaneal arthrodesis
 indications: stage IV disease with a rigid hindfoot, valgus angulation of the talus, and
tibiotalar and subtalar arthritis