Hindfoot valgus

Hindfoot valgus refers to malalignment of the hindfoot in which the mid-calcaneal axis is deviated away from the midline of the body.
On the DP view, this results in an increase in the angle between the mid-calcaneal axis and the mid-talar axis (talocalcaneal angle) 1.
The widening of the talocalaneal angle results in the apparent medial angulation of the mid-talar axis such that the line extends well medial to the base
of the first metatarsal suggesting that the talus is medially angulated.
In fact, the talus is in the correct position (it has no muscular attachments) 1 and it is the rest of the foot that is incorrectly positioned. The entire foot,
under and distal to the talus has been abducted and everted. If the navicular is ossified, it will be laterally displaced.
Since the calcaneus is abducted, the talus looses support of its medial border and the distal portion of the talus drops, leading to a more vertically
oriented talus and the mid-talar line on the lateral view does not intersect the 1st metatarsal.

Hindfoot varus
Hindfoot varus describes a relatively varus position of the calcaneus which is adducted and rotated under the talus. This is best appreciated on
a weightbearing DP foot radiograph as a relative reduction in the angle formed between the mid-talar and mid-calcaneal axes (the talocalcaneal angle).
Hindfoot varus may occur in isolation, but is usually present in patient with congenital talipes equinovarus (club foot).

AP Talocalcaneal angle (Kite's angle)

This is the angle formed by the intersection of a line bisecting the head and neck of the talus and a line running parallel with the
lateral surface of the calcaneus. The range of normal for adults is 15 - 30. An angle greater than 30 would indicate hindfoot
valgus, seen with pes planus (Fig b).

a. Normal AP talocalcaneal angle.

b. Abnormally increased AP
talocalcaneal angle, indicating
hindfoot valgus in pes planus.

http://uwmsk.org/footalignment/doku.php?id=pes_planus

Pes planus
Pes planus (also called flat foot) is a deformity of the foot where the longitudinal arch of the foot is abnormally flattened.

Pathology
It results from loss of the medial longitudinal arch and can be either rigid or flexible. These deformities are usually flexible which means that on nonweightbearing views, the alignment of the plantar arch normalises.
In the paediatric population, the degree of ligamentous laxity of the foot results in relative pes planus that resolves over time 5. Within the first decade
there is spontaneous development of a strong arch.
Pes planus may occur in as many as 20% of the adult population. Although, the majority of patients are asymptomatic and require no treatment. There
is some evidence to suggest that flat feet protects against stress fracture.
There are several conditions that are associated with pes planus:

tarsal coalition 1

tibialis posterior tendon dysfunction

certain connective tissue disorders:

Marfan syndrome 2

Ehlers-Danlos syndrome 2

Radiographic features
Plain film
The longitudinal arch of the foot must be assessed on a weightbearing lateral foot radiograph. If the patient is unable to stand or weightbear, a
simulated weightbearing radiograph should be obtained.
Weightbearing lateral

In normal feet, the relationship between talus and 1st metatarsal results in a straight line being formed along their axis (Meary's angle = 0 degrees).
This is not the case in flat feet where there will be:

loss of the normal straight line relationship

sag at the talonavicular joint or naviculocuneiform joint

Weightbearing DP (dorso-plantar)

It is important to assess:

hindfoot valgus (where the talocalcaneal angle is greater than 35 degrees)

talonavicular uncoverage or subluxation

Pes cavus

Pes cavus refers to a descriptive term for a type of foot deformity with an abnormally high longitudinal arch of the foot (caved in foot).
It can be associated with certain neuromuscular disorders such as

Charcot-Marie-Tooth disease : considered one of the commonest associations in the western world

conditions that cause spastic paralysis

spinal anomalies
o

spinal dysraphisms 4

spina bifida 3

4, 6

Radiographic features
Plain film
A lateral view is the key to assessment as the dorso-plantar view can sometimes be normal unless there an associated abnormality 2.
On a lateral view there is:

increase in the calcaneal inclination angle

angle of the longitudinal arch greater than 170 degrees

the mid-talar axis either extends above the 1st metatarsal or intersects the shaft distal to its midpoint

Hibb's angle less than 150 degrees.

Lateral talar - 1st metatarsal angle

This is an angle formed between the long axis of the talus and first metatarsal on a weight-bearing lateral view. In the normal
weight-bearing foot, the midline axis of the talus is in line with the midline axis of the first metatarsal. An angle that is greater than
4 convex downward is considered pes planus. An angle greater than 4 degrees convex upward is considered a pes cavus.

a. Normal Meary's angle. The long axis of the talus

b. The long axis of the talus is angled plantarward in

Calcaneal pitch (calcaneal inclination angle)

A line is drawn from the plantar-most surface of the calcaneus to the inferior border of the distal articular surface. The angle made
between this line and the transverse plane (or the line from the plantar surface of the calcaneus to the inferior surface of the 5th
metatarsal head) is the calcaneal pitch. A decreased calcaneal pitch (< 20) is consistent with pes planus.

a. Normal calcaneal pitch.

b. Decreased calcaneal pitch indicating pes planus.