DISORDERS OF THE FOOT CONGENITAL, ACQUIRED

Anatomy of foot: hindfoot, midfoot, forefoot

joints: subtalar (talo-calcaneal, talo-navicular, calcaneo-cuboid), Chopart, Lisfranc,
MTP
Weight bearing
3 point support, arches (1st metatarsal head, 5th metetarsal head, calcaneus)
Tibialis posterior tendon anatomy: behind medial malleolus,in a sulcusban
attachment at base of os naviculare. Function: midfoot stabilization
Tibialis post. tendon function:
ankle flexion, midfoot inversion, forefoot adduction
Tibialis post. tendon function in gait: subtalar inversion, stabilization of Chopartjoint in stance phase
Toe extension - Achilles, tibialis post., FDL muscle contract foot inversion.
This movement is painful in tibialis posterior tendinitis
Muscles- tendons to supinate forefoot, invert forefoot, flex ankle joint
and flex toes maintain longitudinal arch medially
Club foot ( pes equionovarus congenitus)
Incidence: 1-2%
Inheritable disorder (poygenetic inheritance)
Boy/girl = 2:1
Aetiology: unknown
Hyppocrates was the first to describe this condition
Deformities: ankle joint in equinus (plantar flexion deformity), subtalar
joint in varus, forefoot in plantar flexion
Tibia internal torsion, atrophyic muscles of the leg
Aetiology:
Primary
Neurological condition (eg. myelomeningocele)
Generalized abnormalities (eg. arthrogryposis congenita)
May be associated with other congenital abnormalities, eg. congenital heart
defect
Pathological changes:
1. Fibrous tissue in tendons, muscles and fasciae of the leg and ankle at the
postero- medial aspect
2. Achilles tendon is shortened and thick
3. Posterior capsule of the ankle is thick
Treatment:
Should begin immediately after birth
Conservative treatment should be tried first
Correction: with straps (elastoplast) or - better - in plaster
If correction is succesful, plaster to be changed weekly, until full correction is
achieved

Aim of treatment: Achieve and maintain correction of the foot

Restore normal joint anatomy and functionat ankle, subtalar and
midtarsal joints
Restore muscle balance
Indication of operative treatment: if conservative measures fail.
Typical operative procedure: postero- medial release of all
shortened structures + lengthen the Achilles tendon + restore joint
anatomy
Operative treatment of club foot: postero- medial release + Achilles
tendon lengthening
Trassection of medial part of tendon distally, and lateral part of tendon
proximally
Release of soft tissues above the flexor hallucis tendon
Subtalar joint capsule is opened
Peroneus tendons are visible
Suture of Achilles- tendon in lengthened position
Postoperative management:
Change of plaster between 4-6 weeks
Use of corrective splints until walking begins
Physio, selective electrotherapy on peroneal muscles
Right foot in supination inversion, weight bearing on the outer edge of
foot
Operation: tibialis anterior tendon transfer from medial side to lateral
side of the foot direction of pull will force foot into eversion - pronation
Tibialis anterior tendon transfer drill hole into 4th metatarsus
All tendon transfers on the foot are made in similar fashion pulled
into drill hole of a metatarsal bone. Direction of pull of tendon will
be different
Result of operation: foot in eversion
Postop: plaster for 2 weeks,, then selective electrotherapy on tibialis
anterior muscle, full weight bearing after 4 weeks
Flat foot:
Congenital flat foot: vertical talus
X-ray: talus is instead of normal horisontal position vertical
Operatrion: open reduction at the talo- navicular joint, K-wire, fixation ,
elongation of tendo Achillis
Tibialis posterior tendon: - hypovascular zone below medial malleolus
vulnerable area (4 cm from tendon attachement), rupture may occur here.

Severe flat foot tarso-metatarsal joints are subluxed- weight bearing at

medial edge of foot
Tibialis posterior dysfunction
acquired flat foot:
Signs
Progressive paiful plano-valgus deformity of foot
Achilles in lateral position (contracture)
Forefoot supination in advanced cases
Too many toes sign (can see too many toes from the back, shouldnt in
normal case)
Definition:
PTTD (posterior tibial tendon dysfunction) : inflammation and /or overload of
tibialis post. tendon
Consequence:
Flattening of longitudinal arch of foot adult acquired flatfoot
Incidence :
USA statistics : 40% of population has undergone operation because of
inflammatory or degenerative disorder of the foot
Tibialis posterior dysfunctio:
management
Conservative:
Before structural deformities develop
Options:
Immobilisation
NSAID
Orthesis insoles, special shoes
Types of supportive devices depends on the mobility or stiffness of foot
deformities
Insoles used for flat foot
Conservative management in flat foot is sufficient, unless a serious
anatomical disorder is found
Exercises to take stuff with the toes and hold it.
Operations on the foot
Similarities with the hand: the foot is also crowded with anatomical structures
Same types of operations can be made on the foot, like on the hand.

Nerve structures, blood vessels, tendons must be safely identified during operation
bloodless field!
Rehabilitation following operations on foot: after any reconstructive operation
plaster must be worn, partial weight bearing is allowed, afterwards ankle and toe
mobility must be quickly restored
Operative treatment: post tib. Tendon dysfunct. clinical management by stages
Synovectomia (1.stdium)
Tendo transfer: 1 or 2 stage
- Condition: Chopard and mobile subtalar joint, a fixed varus foot <12-15
- Method: flexor digitorum longus, tib. post. transfer
- Disadvantage: FDL muscle strength is weaker than the tib. post. muscle (1:3.5) ntransfer alone is not enough, medializl calcaneus osteotomy is required
Grice procedure: arthrodesis (connecting two bones via surgery
Xray signs:
Tarso-metatarsal angle reduced
I.Cuneiform - V.metatarsus reduced distance covered basis (norm.15-25mm)
Talus-1.metatarsus shaft angulation (0 Norm)

calcaneus Corrective osteotomy (calcaneal tuberosity angle-corrected; longitudinal

arch has been restored)
tib.post. tendon dysf. Clinical management by stages:
Operative treatment:
Tendo transfer: intransfer alone is not enough, medialization calcaneus osteotomy
is required

Flat foot due to arthrosis and erosion of subtalar joint

Typical clinical view: rocker bottom foot
Old tear of Achilles tendon reconstruction with fascia of
gastrocnemius postop. 6W plaster, 3 weeks in equinus, 3 weeks
plantigrade crutch walking
Calcaneal spur Haglund exostosis at the attachment of Achilles
tendon
Medial malleolar region course of tibialis posterior nerve passing
through a tunel behind the medial malleolus
Most frequent disorder of the forefoot: bunion on right photo hammer
toe
Primary cause: metatarsus primus varus = varus position of 1st
metatarsal dominance of extensor hallucis tendon
Causes of hallux valgus: metatarsus primus varus (ie. primary varus
position of 1st metatarsal) increased intermetatarsal angle between
1st- 2nd metatarsal
In every form of hallux valgus the head of 1st metatarsal is subluxed in
MTP joint
Painful limitation of movements of 1st MTP joint due to arthrosis

Dropped transverse arch of forefoot, especially below the head of 2nd metatarsal

Hammer toe: hyperextended 2nd MTP joint, hyperflexed PIP joint with
subsequent callosity of skin

Disorder of the short toes: hammer toe imbalance between extensorflexor tendons of toes

Purpose of 1st metatarsal osteotomy: correct inter-.metatarsal angle,

reduce subluxed head of 1st metatarsal
Soft tissue release of lateral structures (eg. abductor tendon) is essential
too
Correction of metatarsus primus varus in hallux valgus: 1st metatarsus osteotomy

<-Osteotomy at the base of

1st metatarsal frequently made

Resection arthroplasty of 1st MTP joint: removal of base of 1st phalanx of

big toe most frequently done in old patients (Keller Brandes
procedure)
For metatarsalgia: Subcapital osteotomy of 2nd metatarsal Helalosteotomy (platar position of head of 2nd metatarsal can be corrected
Neuroma of the interdigital nerve patient is not able to wear tight
fitting shoes