lecture 25 shah flat foot conservative
TRANSCRIPT
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Pathomechanics & Conservative
care:Adult Acquired
Flat Foot
Dr.Rajiv ShahFoot & Ankle Surgeon
‘Foot & Ankle Orthopaedics’Vadodara, Surat, Gujarat
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2
Tibialis PosteriorMedial arch
stabilizers
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Why TP is at risk of rupture/tendinosis?
14mm zone of
ischemia due to lack of mesotenon
Acute curve at medial malleolus
Shallow malleolar groove
Compression & constriction under Flexor retinaculum
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TP dysfunction: pathophysiology
Repetitive micro
trauma
Tendon & sheath
inflammation
Tendon elongation
Tendon rupture
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AAFD: pathophysiology
Ruptured TP
Failed medial restrains = Flat foot
No locking of TT joints +
unopposed pull of peroneus brevis everts heel =
Heel valgus
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The longitudinal axis of 1st metatarsal and talus forms zero degree angle-Meary’s angle
Weight bearing biomechanics
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On weight bearing talus plantarflexes and slides distally on Calcaneum, which is restrained by spring ligament
Weight bearing biomechanics
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Calcaneum also plantarflexes and plantar fascia is stretched to limit arch collapse
Weight bearing biomechanics
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Navicular and cuneiform dorsiflex, evert & abductwhich is limited by TP
Weight bearing biomechanics
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Metatarsals also dorsiflex and abduct
Weight bearing biomechanics
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Final picture on weight bearing
Weight bearing biomechanics
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Midfoot bones and metatarsals dorsiflex & abduct & flatfoot results
If these restraints fail, then???Talus plantarflexes - moves distally and rotates medially
Calcaneum planterflexes & goes in valgus
Weak spring lig & ITCL fails to support
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Clinical Stages
Stage 1TendinopathyNormal tendon lengthNo deformity
Stage 2 Tendon
lengthening
Flexible deformity
Stage 3 Tendon
lengthening
Fixed deformity
Stage 4
Fixed deformity
Talus tilted in ankle(ankle involvement
Dereymaeker: Stage Zero
Biomechanical abnormality
No symptoms
Stage 2: 2a & 2b
2a: Medial symptoms
2b: Lateral symptoms
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Clinical testsSingle Limb Heel Raise Test
Too many toes signHeel ValgusTP function evaluation
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Weight bearing X-rays Lateral View: break in Talo-1st MT line
(Meary’s Line) Altered talar declination angle
NormalAcquired Flatfoot
Radiological diagnosis
Normal
Flat foot
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AP View: talo-navicular uncoverage Forefoot abduction
Radiological diagnosis
Normal < 7 degree
AAFD > 7 degree
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Stage 2a
Less than 30% medial talar head uncoverage (or no lateral incongruence)
No clinical forefoot abduction
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More than 30% medial talar head uncoverage or lateral incongruence
Significant clinical forefoot abduction
Stage 2b
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Lateral Incongruence
Congruent 2a
Incongruent 2b
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Arthritis of subtalar, TN & CC joints Forefoot abduction Heel valgus
Radiological diagnosis: Stage 3Radiological diagnosis: Stage 4
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Tendon pathology, tear, degeneration
Spring ligament visualization
Usually not necessary
Magical effect
MRI???
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Stage 1: essentially conservative
Stage 2: conservative care for at least 6 months or more
Stage 3 & stage 4: patients with co-morbid conditions & unfit for surgery
Conservative care
Stage 1: prevent tendon rupture by giving rest to tendon
Stage 2:prevent progression of deformity
Stage 3 & stage 4: accommodation of deformity
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NSAIDS
Conservative care: Modalities
Management of systemic disease
Physical therapyStrengthening
TherabandIontophoresisCryotherapy
OrthoticsMedial wedgeMedial column
postHeel alterations
UCBLFoot moldBK cast
Boot
Activity modification
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That’s all…Thank you all..
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IFFASCON- 15 at Ludhiana August 28th, 29th & 30th, 2015
20 international faculties
Day 1: Parekh family foundation workshop (7 modules)
Day2 & 3: ConfenrenceA must attend meeting for 2015!