Flat foot is one of the most common foot pathologies and different clinical assessment are available.

1. PLANOVALGUS FOOT (PES PLANUS , FLAT FOOT)
CLINICAL EXAMINATION
HUDA ALFATAFTA, MASTERS BY RESEARCH
UNIVERSITY OF SALFORD, UK
LECTURER AT UNIVERSITY OF JORDAN/ ORTHOTICS AND PROSTHETICS DEPARTMENT

2. FLAT FOOT
EXAMINATION
2018
Introduction Flat Foot
Risk
factors
Clinical
symptoms
Gait
patterns
Clinical
tests
Gait analysis
Treatments
PT P&O surgery The
end
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Foot print tests

3. FOOT
▪ The foot is a complex anatomical structure.
▪ Functions:
 It acts to transmit force between the lower limb and the ground, allowing stable
ambulation and stance.
 During gait the foot functions as a flexible shock-absorber, deforming to uneven
surfaces before undergoing a series of biomechanical changes which allow it to act
as a rigid lever to exert force.
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4. ARCHES OF FOOT
▪ Three arches : medial and lateral longitudinal arches, and transverse
arche.
▪ The medial longitudinal arch consists of the calcaneum, talus, navicular,
medial, intermediate and lateral cuneiforms and the first three
metatarsals.
▪ The talus sits at the apex of the arch (key stone) and confers stability by
acting as a wedge between the calcaneum and navicular
▪ Half the body-weight passes through the apex of the arch whilst
standing.
▪ The ends of the ach are unable to move apart due to the tight plantar
fascia which connects them . Hence arch height is maintained
“notrmaly”
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5. THE MEDIAL
LONGITUDINAL
ARCH
Stabilizing factors
Stabilizing models
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6. STABILIZING FACTORS (STATIC AND DYNAMIC)
Static factors
▪ The most important primary stabilizer
is the plantar fascia,
▪ followed by the long and short plantar
ligaments and then the spring
ligament.
▪ Then, bony congruency
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Dynamic factors
▪ tibialis posterior and other long flexors
are important dynamic stabilizers.
▪ releasing these structures without
releasing any static stabilizers has only
a modest effect on arch height.
▪ One study found the result of releasing
posterior tibial tension is associate
with 0.5 mm reduction in arch height

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8. STABILIZING MODELS
THE BEAM MODEL
▪ in the beam model, a load is applied to
the apex of the arch generating
compressive forces on the dorsal
surface and tensile forces on the
plantar surface.
▪ Stability in this model results from
bony congruency and ligamentous
attachments
THE TRUSS MODEL.
▪ In the truss model, there is a triangular
arrangement of structures.
▪ The bones of the arch are able to pivot
about their apex whilst the tough
plantar fascia forms the third side.
▪ This is firmly attached to the medial
and lateral calcaneal tuberosities
proximally and its slips insert into the
plantar plate and the fibrous flexor
sheathes distally
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▪ the beam model ▪ the truss model.

10. WHAT IS FLAT FOOT
▪ collapse or disappearance of the medial
longitudinal foot arch and is associated with several
three-dimensional foot deformities associated with
a rotational hindfoot abnormality and heel valgus
▪ All infants are born with flatfoot, and the
longitudinal arch of the foot develops during the
first decade, but the prevalence of flatfoot is 37%–
59.7% in children 2–6 years of age and 4%–19.1% in
those 8–13 years of age .
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11. RISK FACTORS
GROUP A
▪ BMI, OBESITY
▪ Age
▪ Pregnancy
▪ heredity
GROUP B
▪ tibialis posterior dysfunction.
▪ Ligament laxity
▪ rotational abnormalities of the lower
limbs
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12. CLINICAL SYMPTOMS
▪ Pain on the sole side of the forefoot
▪ plantar pressure under the talar head
▪ Pain between the tip of the fibula and
the calcaneus.
pain
Low
activity
level
significant
change in
foot shape
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13. GAIT PATTERNS
▪ Eversion of the foot at the
talonavicular and talocalcaneal joints
▪ Valgus foot from posterior  the
medial border of the foot approaching
the ground
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14. CLINICAL FOOT CLASSIFICATION MEASURES
FLAT FOOT

15. STEPS OF EXAMINATION
▪ Look at standing foot posture, swelling, hindfoot alignment, shoe and assess gait.
▪ Feel for localized tenderness and the nature of any swelling.
▪ Move each joint systematically, checking for pain, crepitus or stiffness.
▪ Special tests
▪ Radiographs
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16. REARFOOT ANGLE (RFA)
▪ Briefly, four locations were palpated and marked using a skin
marker pen (Fig. 1A). These were:
▪ (1) the base of the calcaneus; (2) the Achilles tendon attachment;
(3) the centre of the Achilles tendon at the height of the medial
malleoli; (4.) the centre of the posterior aspect of the shank 15
cm above marker three.
▪ The RFA was measured using a goniometer. The arms of the
goniometer were aligned with the line connecting marker one
and two (line 1) and the other arm with the lines connecting
marker three and four (line 2).
▪ The RFA was measured as the acute angle between the projection
of line one and line two.
▪ RFA ≥ 5° valgus represented a pronated foot type, 4° valgus to 4°
varus a neutral foot and ≥ 5° varus a supinated foot
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17. MEDIAL
LONGITUDINAL ARCH
ANGLE (MLAA)
▪ the midpoint of the medial malleolus, the most prominent aspect
of the navicular tuberosity and the most medial prominence of
the first metatarsal head were palpated and marked using a skin
marker pen.
▪ The MLAA was measured using a goniometer with the centre of
the goniometer aligned with the navicular mark and the arms
aligned to connect the navicular mark with the medial malleolus
and first metatarsal head markings. The obtuse angle was
recorded as the MLAA.
MLAA < 130° represented a pronated
foot type, 130° to 150° a neutral foot
type and > 150° a supinated foot type
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18. NAVICULAR DROP
TEST (NDT).
▪ Navicular Drop Test (NDT). Initially the most prominent aspect of
the navicular tuberosity was palpated and marked with a skin
marker pen. A piece of card was placed next to the medial aspect
of the foot and the height of the navicular in a relaxed standing
position marked on the card. The foot was then manipulated into
subtalar joint neutral as determined by congruence of the talar
head, and the process outlined above repeated.
▪ ND was recorded as the difference in navicular height between
STJN and relaxed standing.
The normal foot group included
subjects with an NDT of 5–9mm
ND > 9 mm represented a pronated foot
type, 5 to 9 mm a neutral foot and < 5
mm a supinated foot
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19. FOOT POSTURE
INDEX (FPI-6)
▪ The FPI is a six-item clinical assessment tool used to evaluate foot
posture. It has acceptable validity and good intra-rater reliability
(ICC = 0.893–0.958).
The FPI evaluates the multi-segmental nature of
foot posture in all three planes;
It does not require the use of specialised
equipment.
Each item of the FPI is scored between 2 and +2.
Foot type was classified according to normative
values with scores of ≥ 8 representing a pronated
foot type, 0 to 5 a neutral foot and ≤ -1 a
supinated foot
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21. THE LEVEL OF AGREEMENT BETWEEN COMMON
CLINICAL FOOT CLASSIFICATION MEASURES.
▪ Foot classification across the two test occasions was almost perfect for MLAA (Kw =
0.92) and FPI-6 (Kw =0 .92), moderate for RFA (Kw = 0.60) and fair for ND (Kw =0 .40)
for comparison within the measures.
▪ Overall agreement between the measures for foot classification was moderate (Kf =
0.58).
▪ Conclusion: The findings reported in this study highlight discrepancies between the
chosen foot classification measures. The FPI-6 was a reliable multi-planar measure
whereas navicular drop emerged as an unreliable measure with only fair agreement
across test sessions. The use of this measure for foot assessment is discouraged.
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22. FOOT PRINT
▪ Arch index (AI)
▪ calculated as the ratio of the area of the middle third
of the footprint to the entire footprint area. The foot
was defined as high-arched if the AI was lower than
21% or flat if the AI was higher than 28%.
▪ AI= B/ (A+B+C)* 100%
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23. FOOT PRINT
▪ Russian author method
▪ If the foot print occupies three out of five fields, it is the first degree; four out of five
means the second degree, while five out of five means the third degree of the
suspended foot.
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24. RADIOGRAPHIC MEASURES
▪ Simple standing anteroposterior and lateral radiographs of weight-bearing feet were
obtained in a digitalized manner from each subject. We measured the four angles
commonly used to assess flatfoot on the lateral radiograph, including 1) lateral talo-
first metatarsal angle (Meary’s angle), 2) talo-calcaneal angle, 3) metatarsal angle,
and 4) calcaneal pitch
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25. Normal Supination (high
arch )
Pronation (flat
foot)
lateral talo-first
metatarsal angle
(Meary’s angle)
Zero- 4 upward
or downward
4 or more
upward
4 or more
downward.
mild <15º
moderate: 15-
30º
severe: 30º
talo-calcaneal
angle
25-45 degrees Less than 25
degrees
over 45 degrees
metatarsal angle Not common to be used
calcaneal pitch 18 to 20° More than 20 Less than 18
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The red highlighted
tests are widely used

26. GAIT ANALYSIS AND PRESSURE MEASUREMENT
▪ Platform with force-sensitive sensors
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27. FLAT FOOT STAGES
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Stage
Stage I by symptoms of pain and swelling along the posterior tibial tendon without
visible changes of foot alignment
Stage II asymmetry of alignment with hindfoot valgus and forefoot abduction
exaggerated on the symptomatic foot. have weakness with inversion and
difficulty performing a single foot heel raise.
Stage III flatfoot represents a progression of all the clinical signs but not rigid
Stage VI Rigid ankle valgus deformity

28. FLEXIBLE OR RIGID ?
 Bony structure on not ?
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Jack’s test Tip toe standing

29. REHABILITATION TREATMENT OPTIONS
FLAT FOOT

30. TREATMENTS
PHYSIOTHERAPIST
▪ foot exercises
ORTHOTIST
▪ Arch support
▪ Wedge
▪ SMO
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vs. SURGEON
Calcaneal osteotomy
Subtalar arthrodesis
 Triple arthrodesis
vs.

31. PT
EXERCISES OPTIONS
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32. P&O
ORTHOTICS INTERVENTIONS
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33. SURGERY

34. REFERENCES
▪ Jankowicz-Szymańska, A., Wódka, K., Kołpa, M., & Mikołajczyk, E. (2018). Foot longitudinal arches in obese, overweight
and normal weight females who differ in age. HOMO, 69(1-2), 37-42.
▪ Pardo, F. J. V., del Amo, A. L., Rios, M. P., Gijon-Nogueron, G., & Yuste, C. C. (2018). Changes in foot posture during
pregnancy and their relation with musculoskeletal pain: A longitudinal cohort study. Women and Birth, 31(2), e84-e88.
▪ Kangas, J., Dankaerts, W., & Staes, F. (2011). New approach to the diagnosis and classification of chronic foot and ankle
disorders: Identifying motor control and movement impairments. Manual therapy, 16(6), 522-530.
▪ Lee, J. S., Kim, K. B., Jeong, J. O., Kwon, N. Y., & Jeong, S. M. (2015). Correlation of foot posture index with plantar
pressure and radiographic measurements in pediatric flatfoot. Annals of rehabilitation medicine, 39(1), 10-17.
▪ Young, C. C., Niedfeldt, M. W., Morris, G. A., & Eerkes, K. J. (2005). Clinical examination of the foot and ankle. Primary
Care: Clinics in Office Practice, 32(1), 105-132.
▪ Cebulski-Delebarre, A., Boutry, N., Szymanski, C., Maynou, C., Lefebvre, G., Amzallag-Bellenger, E., & Cotten, A. (2016).
Correlation between primary flat foot and lower extremity rotational misalignment in adults. Diagnostic and
interventional imaging, 97(11), 1151-1157.
▪ Lever, C. J., & Hennessy, M. S. (2016). Adult flat foot deformity. Orthopaedics and Trauma, 30(1), 41-50.
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35. CONT.
▪ Roche, A., Hunter, L., Pocock, N., & Brown, D. (2009). Physical examination of the foot and ankle by
orthopaedic and accident and emergency clinicians. Injury, 40(2), 136-138.
▪ Langley, B., Cramp, M., & Morrison, S. C. (2016). Clinical measures of static foot posture do not
agree. Journal of foot and ankle research, 9(1), 45.
▪ DELAND, J. T. (2004). ANATOMY AND BIOMECHANICS OF THE FOOT AND ANKLE. Foot and Ankle, 1.
▪ Rao, S., Riskowski, J. L., & Hannan, M. T. (2012). Musculoskeletal conditions of the foot and ankle:
assessments and treatment options. Best practice & research Clinical rheumatology, 26(3), 345-
368.
▪ Brockett, C. L., & Chapman, G. J. (2016). Biomechanics of the ankle. Orthopaedics and
trauma, 30(3), 232-238.
▪ Haendlmayer, K. T., & Harris, N. J. (2009). (ii) Flatfoot deformity: an overview. Orthopaedics and
Trauma, 23(6), 395-403.
▪ Pauk, J., & Ezerskiy, V. (2011). The effect of foot orthotics on arch height: prediction of arch height
correction in flat-foot children. Biocybernetics and Biomedical Engineering, 31(1), 51-62.
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