What Happens to the Paediatric Flat Foot? Peter J Briggs Freeman Hospital Newcastle upon Tyne

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 Flat foot 8.6% Non-shoe wearers 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 Flat foot 3.24% Between 6 15 Flat foot 3.27% Over 16 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 Os Calcis (Calcaneum) Talus 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 25% Long and short plantar ligaments 10% Spring ligament 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 1 st three metatarsals Passive toe dorsiflexion causing arch elevation and heel supination Stabilisation of 1 st 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

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