PES PLANUS

MUJAHIDA ISLAM

Although flexible pes planus rarely requires

surgical treatment, rigid pes planus
frequently causes enough symptoms to
justify operation.
Congenital vertical talus is probably the
most severe example of rigid pes planus, it
is most often treated in infancy.
Tarsal coalition, another common cause of
rigid pes planus.

PES PLANUS

FLEXIBLE PES PLANUS

RIGID PES PLANUS

PES PLANUS
Pes planus (flatfoot) by convention refers to
loss of the normal medial longitudinal arch.

FLEXIBLE PES PLANUS

If an acceptable medial longitudinal arch
does appear with nonweight bearing, pes
planus is termed flexible.

RIGID PES PLANUS

If an acceptable medial longitudinal arch
does not appear with nonweight bearing,
pes planus is termed Fixed, or Rigid.

1.

Congenital Vertical Talus.

2.

Tarsal Coalition.

3.

Accesory naviular bone.

Tarsal Coalitionthe fibrous, cartilaginous,

or bony fusion of two or more of the tarsal
bones, often resulting inTALIPES
PLANOVALGUS

A block between two bones, which may be

osseous cartilaginous or fibrous.

The cause of tarsal coalition is almost

irrefutably a failure of primitive
mesenchyme to segment by cleavage in
the 27- to 72-mm fetus and produce the
normal peritalar joint complex.

A unifactorial disorder of Autosomal

Dominant Inheritance with nearly full
penetrance

Coronal section
through foot of
72.3-mm fetus
showing complete
medial
talocalcaneal
bridge.

Calcaneonavicular .
Talocalcaneal.
Talonavicular
Calcaneocuboid.
Naviculocuboid.
Naviculocuneiform.
Massive tarsal coalition.

Calcaneonavicular coalition (Fig. 79-13 B)

was described by the anatomists
Zuckerkandl (1877), Holl (1880), and Pfitzner
(1896) after they performed laboratory
dissections.

It was not until 1920 that Slomann

suggested the association of pes planus,
tarsal coalition, and rigidity of the hindfoot.

Although probably present since birth, the

Calcaneonavicular bar does not ossify until 8 to
12 years old.

Before this period, presumably because of the

malleability of the cartilage surrounding the
primary ossification centers of the peritalar
complex, significant symptoms are rare.
It is believed that as the cartilage ossifies, hindfoot
stiffness results, and the patient's ability to
withstand the stress of vigorous childhood activity
declines.

Complete
Bony(synostosis)

Incomplete
Cartilaginous(synchondrosis)
Fibrous(syndesmosis)

Incomplete coalitions, that is,

cartilaginous or fibrous, usually are the
more symptomatic.

Symptoms
1. Vague dorsolateral foot pain centering
around the sinustarsi.
2. Difficulty walking on uneven surfaces.
3. Foot fatigue.
4. Occasionally a painful limp.


1.
2.

Signs
May or may not show significant reduction
of subtalar motion.
Flattening of the longitudinal arch.
So a high index of suspicion is
necessary in this patient profile.

The abnormal bar runs

from the anterior process
of the calcaneus just
lateral to the anterior
facet dorsally and
medially to the lateral
and dorsolateral
extraarticular surface of
the navicular.
It usually is 1 to 2 cm
long 1 to 1.2 cm wide.

1.

In a bar with a cartilaginous or fibrous interface,

the adjacent bony margins are irregular and
indistinct.

2.

The talar head might appear small and

underdeveloped.

3.

Beaking of the dorsal articular margin of the

talus, so common in talocalcaneal coalition, is
uncommon in calcaneonavicular coalition

In a review of plain
radiographs of tarsal
coalitions, also noted
that the bar and
altered navicular
morphology could be
seen on Standard
Anteroposterior
radiographs.

CT should not be
needed to diagnose
this type of coalition.

To identify coalition
earlier.

To diagnose cases of
recurrence.

Conservative

Surgical

A trial of reduced activity or cast

immobilization or both is recommended.

A patient may be rendered asymptomatic for

varying periods or even indefinitely after 4
to 6 weeks in a cast. Intermittent casting for
short periods, with lengthy intervals of
noncasting, might be all that is required.

The mere presence of a tarsal coalition does

not mean surgery should be recommended.

if patients with tarsal coalition reach their

20s with few or no symptoms, they
frequently remain asymptomatic or are only
mildly symptomatic.

Indication
If a trial period of casting and the use of a
molded, firm arch support do not allow an
adolescent to participate in activities he or
she enjoys, surgical treatment is
recommended.


1.
2.
3.

The most commonly accepted surgical

treatments are
Resection of the Calcaneonavicular Bar
with interposition of muscle or fat.
Subtalar arthrodesis.
Triple arthrodesis.

The contribution of Harris and Beath in the

description of talocalcaneal coalition in 1948
cannot be overemphasized. Before this time,
rigid pes planus, with or without peroneal
spasm, had never been attributed to
talocalcaneal coalition.

They reported a talocalcaneal bridge of

bone between the sustentaculum and talus in
12 of 17 feet with rigid pes planus.

Talocalcaneal
coalition. A and B,
Fifteen-year-old boy
with bilateral medial
facet talocalcaneal
coalition.

The talocalcaneal bridge ossifies either

completely or incompletely between 12 and
16 years old, which is later than the
ossification of the calcaneonavicular bar
and usually is diagnosed in older
adolescents or adults.

1.
2.

Symptoms
The symptoms are similar to those of
calcaneonavicular coalition
Foot fatigue
Pain around the hindfoot on increased
activity.

If routine views of the

foot plus the coalition
view do not confirm a
suspected medial
talocalcaneal coalition,
CT scan may be
helpful.

Standard for diagnosis

of talocalcaneal
coalitions

MRI may be helpful in

depicting all types of
coalitions, including
fibrous coalitions.

Conservative

Surgical

1.

A trial of conservative treatment is

recommended, including reduced activity, 4
to 6 weeks in a short leg walking
castfollowed by a period of wearing firm
arch supports.

2.

A Steroid Injection within the sinus tarsi.

Indication
Failure of conservative treatment.

1.

The most commonly accepted surgical

treatments are
Resection of a Middle Facet Tarsal Coalition

2.

Triple arthrodesis.