MODULE 2: Foot Pathologies

Session 1: Pes Planus

INDEX
OBJECTIVES .......................................................................... 3
PES PLANUS .......................................................................... 4
BIBLIOGRAPHY .................................................................... 25

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OBJECTIVES
The main goals to be attained by the student during this work session are summarized
in the following points:

Know the different disorders or diseases which lead to the shortage or absence
of the medial longitudinal arch (Pes Planus or flat foot).

Identify the different typologies of flat foot.

Obtain knowledge of the biomechanical assessment of flat foot diseases.

Know the most relevant quantitative methods for the assessment of Pes
Planus.

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PES PLANUS
INTRODUCTION
Pes Planus is a generic term for a foot with a depressed or absent medial longitudinal
arch, rearfoot valgus, forefoot abduction and an increased contact area with the
ground.
There are two main types of flat foot:

Congenital flatfoot: appears as a result of heredity factors and is present from

birth. Diseases such as flat foot by vertical talus and flat foot by tarsal coalition
are congenital.

Acquired flatfoot: caused by non hereditary factors, such as neuromuscular

disorders, trauma, habits or incorrect footwear. Due to these factors, the
normal foot structure is altered, which was not pathological previously.

The adult acquired flatfoot is a deformity that results from the loss of dynamic and
static supportive structures of the medial longitudinal arch. The severity of the
deformity is dependent upon the role of ligamentous disruption on the rearfoot that
can be determined by careful clinical examination. Treatment of the adult flatfoot
requires an understanding of the biomechanical effects of deforming forces, tendon
dysfunction, ligament disruption, and joint subluxation. (Figure 1)

Figure 1. Pes planus

There are several etiologies (causes) of Pes Planus. The most important are:
1. Posterior Tibial Dysfunction.
2. Rearfoot valgus / Calcaneal valgus.
3. Forefoot varus.
4. Rheumatic Disease.
5. Neurologic Disease.
6. Diabetic foot.
7. Ligamentous hyperlaxity.
There are four different kinds of flat foot. It is important to diagnose the correct flat
foot and if possible ascertain the cause.
Both are important for the final (orthopaedic) custom shoe prescription.
When diagnosing a flat foot the abnormal position must be described as well as the
possibilities for correcting the position.

ONLINE TRAINING

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Position abnormalities that are seen in flat feet, individually or in combination, are as
follows:

Planus: the calcaneus is more horizontal and the longitudinal arches have fallen
(Figure 2).

Valgus: the calcaneus is tilting in valgus >6

Valgus-abductus: valgus tilt of the calcaneus with an abduction of the mid- and
forefoot (too many toes sign).

Planovalgus-abductus:
position.

combination

of

pes

planovalgus

and

abducted

Figure 2. Foot position abnormalities in children

In response to the possibility for position correction we can divide pes planovalgus
into:

The supple or dynamic pes planovalgus.

The partially supple or hypodynamic pes planovalgus.

The stiff, contracted or adynamic pes planovalgus.

In the case of dynamic pes planovalgus, correction occurs on the valgus position of
the calcaneus and the medial foot arch while the child is standing on his toes, when is
sitting on a chair with legs dangling or while the investigator passively hyperextends
the hallux while the child stands on his feet: its the Jacks test. In this case is
positive. (Figure 3).

Figure 3. Hyperextends the hallux

The difference with the hypodynamic pes planovalgus is that there is no complete
correction during the above-mentioned tests. The investigator can correct fully while
passively manipulating the heel bone and the tarsis.

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In the case of contracted Pes planovalgus, no correction occurs during the tests
described above, and passive correction is not possible either.
There are many possible reasons for the occurrence of a dynamic pes planovalgus.
Most children have pes planus (valgus) up to the age of two. It is accentuated by the
presence of subcutaneous fat on the longitudinal arch.
Between the ages of two to five years old the supple pes planus (valgus) appears in
approximately 30 to 40% of children. Between the ages of five to ten it is only still
present in 10% of children.
In other words: the supple pes planus (valgus) usually corrects itself spontaneously
and does not need to be treated.
If the parent still wants to do something, however, he/she can make sure that the
child has well- fitting shoes and that there is a heel cap in the shoe to ensure that the
heel bone doesnt end up in a valgus position (too much).
They may also be causes for the appearance of a supple pes planovalgus that do need
extra provisions.
Example
Hyperlaxity with pain (Figure 4) and hypotonic muscles.

Figure 4. Foot position abnormalities in children

Some focus points for (orthopaedic) custom shoe provisions:

Corrective foot bed with good pressure distribution.

Sturdy heel cap running right the way forward.

The hypodynamic and contracted pes planovalgus can be congenital, without a known
cause, or may arise due to disorders like spina bifida or infantile encephalopathy.
In the case of these forms of pes planovalgus corrective and/or foot shape accepting
foot beds or more elaborate (orthopaedic) custom shoe provisions are usually
provided.
Contracted pes planovalgus is sometimes treated surgically. Also, after surgery its
recommended do an orthopaedic insoles.
The pes planus (valgus) with an abduction component is usually also treated with
corrective and/or foot beds moulded to the shape of the feet.

ONLINE TRAINING

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BIOMECHANICAL ASSESSMENT
Clinical exploration
Profile view:

Flexible planus foot:

o

Disappearance of the internal longitudinal arch when weight bearing.

Reappearance of the internal longitudinal arch when non weight bearing.

Jacks Test (hyperextension of the hallux): appearance of the internal

longitudinal arch and varization of the calcaneus, due to the spring effect that
plantar fascia exerts when it is shortened by the hyperextension of the hallux,
pulling the calcaneus to a varus position. Jacks test is positive.

Heel Rise Test: Patient should stand with his natural Fick angle and
sustentation base. After that, patient should raise the heel. If the patient
presents a flexible planus foot the heel moves in varus position. Heel rise test
is positive.

Rigid planus foot:

o

Appearance of three prominences:

Internal malleolus.
Talus head.
Navicular bone.

Jacks Test (hyperextension of the hallux): non appearance of the internal

longitudinal arch hyperextending the first toe.

Heel Rise Test: when the patient presents a rigid planus foot the heel does not
move in varus position.
Flexible
planus foot

Rigid planus
foot

Jacks test

Positive

Negative

Heel rise
test

Positive

negative

Type of planus foot (rigid or flexible)

Depending on the results of the Jacks and Heel Rise tests

Anterior frontal view:

Abducted foot.

The talus inclination involves a forward displacement of the external malleolus.

Posterior frontal view:

Valgus position of the heel on loaded foot without neutralized subtalar joint:
o

Bisector of calcaneus > 6 of valgus.

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Bisector of calcaneus
Obtained from:

Posterior frontal view.

Tools:

Goniometer. Copy pencil.

Definition:

Bisector of calcaneus.

Methodology:

1. Palpate the medial and lateral edge of the two

proximal thirds of the calcaneus.
2.- Mark the following three points:

Proximal point.

Distal point.

Central point between the proximal and distal

one.

3. Extend a line linking the three points to include the

distal third of calcaneus (bisector of calcaneus).
4. Measure the angle formed between the bisector of
calcaneus and the vertical axis with help of a
goniometer.
Criteria:

Bisector of calcaneus > 6 of valgus : Calcaneus

valgus

0 < Bisector of calcaneus < 6 of valgus: Range

of normality

Bisector of calcaneus > 0 of varus: Calcaneus

varus

Image:

Stage of valgus position of the heel:

o

Heel maximally pronated:

Subtraction between bisector of calcaneus obtained with and without
neutralizing the calcaneus: between 0 and 2.
Pes planus not related to the pronated position of the rearfoot.

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Heel not maximally pronated:

Subtraction between bisector of calcaneus obtained with and without
neutralizing the calcaneus > 2.
Pes planus related to the pronated position of the rearfoot. It is possible to
correct this valgus deformity.

Symptomatology

Fatigue during the gait.

Metatarsalgia, especially if exists an associated short Achilles tendon.

Pain at:
o
o
o
o
o
o

Forefoot.
Rearfoot.
Ankle.
Fascia.
Internal edge of the foot, in the insertion of the posterior tibialis.
Dorsal part of the foot (in case of a rigid foot).

Clinical forms

Congenital planus foot:

o It appears as a consequence of hereditary factors and it is present at birth.

Acquired planus foot:

o It appears from extra-hereditary factors such as neuromuscular alterations,
traumatisms, incorrect footwear and habits, overweigh, hormonal
alterations or rheumatisms that alter a non pathological lower limb
structure.

Gait analysis

First grade:
o

Normal plantar support phases.

Second grade:

During the third phase of the plantar support the external edge support is
constant. Also, a backwards intern prolongation of the anterior support and a
forward intern prolongation of the posterior support exist. That is, the internal
edge contacts the ground with more or less intensity adopting any of the three
represented shapes:

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Third grade:
o

A total contact of the foot plant with the floor exists during the second phase.
During the third phase, talus head and navicular bone form a prominence at
the internal edge of the foot, giving a footprint similar to the flat foot fourth
grade imprint.

Fourth grade:
o

Second and third phases are altered, so that the footprint is similar to the static
support imprint.

Baropodometry (Pressure insoles or pressure platform)

Overpressures on the medial zone of the calcaneus during the initial heel
contact.
Overpressures on the internal longitudinal arch during themid-stance phase.
Overpressures on the central and medial metatarsals during the take-off phase.

ONLINE TRAINING

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Plantar morphology (Footprints)

QUALITATIVE EVALUATION:

First grade:
o

Midfoot support>1/3 of the total foot width (external support slightly

increased).

Second grade:
o

A contact of internal and external edges of the foot exists, but the plantar arch
remains (it doesnt contact to the ground).

Third grade:
o

Plantar arch disappears completely. The width of the arch support is equal to
the metatarsal support width.

Fourth grade:
o

Dominant internal protuberance on the footprint, and appearance of a wide

area on the external anterior and middle zones that do not appear on the
footprint. Convex foot.

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QUANTITATIVE EVALUATION:

Chippaux Index

Obtained from:

Footprint.

Tools:

Conventional or digital podoscope, ink footprint and

photopodogram.

Definition:

Indicates the area of the midfoot on a smooth surface.

Methodology:

It is measured dividing the value of the narrower zone of the

midfoot (E) by the value of the parallel line on the wider zone of
the forefoot (D), and multiplying by 100.
Chippaux Index = 100*E/D

Criteria:

Image:

ONLINE TRAINING

Chippaux criteria:
o Chippaux Index < 25% Tendency to cavus foot.
o 25% < Chippaux Index < 45%: Normality range
o Chippaux Index > 45%: Tendency to flatness
and/or pronation.
Smirak and Viladot criteria:
o Chippaux Index < 33% Tendency to cavus foot.
o 33% < Chippaux Index < 50%: Normality range.
o Chippaux Index > 50%: Tendency to flatness
and/or pronation.

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Staheli index
Obtained from:

Footprint

Tools:

Conventional or digital podoscope, ink footprint and

photopodogram.

Definition:

Relation between midfoot and rearfoot.

Methodology:

It is measured by dividing the value of the narrower

zone of the midfoot (E) by the value of the parallel line
on the wider zone of the rearfoot (F).
Staheli index Index = E/F

Criteria:

Staheli index < 0.6: Tendency to cavus foot.

0.6 < Staheli index < 0.7: Normality range.

Staheli index > 0.7: Tendency to flatness

and/or pronation.

Image:

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Clarke Index
Obtained from:

Footprint.

Tools:

Conventional or digital podoscope, ink footprint and

photopodogram.

Definition:

Objective method for measuring internal longitudinal

arch.

Methodology:

Angle between lines A, that joins the more internal

point of the forefoot and the more internal point of
the rearfoot, with line B, that joins the more internal
point of the forefoot with the deeper part of the
footprint.

Criteria:

Clarke Angle < 31: Tendency to flatness

and/or pronation.

31 < Clarke Angle < 45: Normality range.

Clarke Angle > 45: Tendency to cavus foot.

Image:

ONLINE TRAINING

Module 2 Session 1 __ 15/26

Hernndez Corvo Index

Obtained from:

Footprint.

Tools:

Conventional or digital podoscope, ink footprint and

photopodogram.

Definition:

Indicates a classification of the foot depending on the

shape of the footprint.

Methodology:

1. Draw a line tangent to the more internal point of

the forefoot (point 1) and the more internal point of
the rearfoot (point 1). This line is named as initial
trace.
2. Detect the upper point of the forefoot (point 2) and
the lower point of the rearfoot (point 2).
3.- Draw a perpendicular line to the initial trace
passing by point 2 and another one passing by point
2.
4. The distance on the initial trace between point 1
and point 2 is named as fundamental mean. This
distance must be noted down and copied along the
initial trace as many times as fit on the footprint.
5. Draw lines 3, 4 and 5, perpendicular to the initial
trace.
6. On the external part of the footprint, draw following
lines:

Line 6: perpendicular to line 3, and below line 3.

Line 7: perpendicular to line, 4 and below line 4.

Line 8: perpendicular to line 5, and below line 5.

7. Measure value of X or forefoot width, that is the

distance between the initial trace and line 6, parallel
to line 3.
8. Draw line 9, perpendicular to line 4 and line 5, that
pass by the more internal point of the footprint
between line 4 and line 5.
9. Measure value of Y or midfoot width, that is the
distance between line 7 and line 9, parallel to line 4.
10. Measure distance AY, from line 9 to the initial
trace (it is the complementary distance to Y).

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Hernndez Corvo Index

11. Measure value of TA or rearfoot width, that is
the distance between the initial trace and line 8,
parallel to line 5.
12.- Apply following formula:
Hernndez Corvo Index = 100*(X-Y)/X

Criteria:

Image:

ONLINE TRAINING

0% < Hernndez Corvo Index < 34%: Flat

foot.

35% < Hernndez Corvo Index < 39%: Flat

foot Normal foot.

40% < Hernndez Corvo Index < 54%: Normal

foot.

55% < Hernndez Corvo Index < 59%: Normal

foot Cavus foot.

60% < Hernndez Corvo Index < 74%: Cavus

foot.

75% < Hernndez Corvo Index < 84%: Strong

Cavus foot.

85% < Hernndez Corvo Index < 100%: Extreme

Cavus foot.

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Valgus Index
Obtained from:

Footprint.

Tools:

Conventional or digital podoscope, ink footprint and

photopodogram.

Definition:

Indicates the relationship or position of the Calcaneus

with the longitudinal axis of the foot in statics.

Methodology:

1. Obtain the Malleolus axis (AB), determined by:

1.1 The projection of the internal Malleolus (A) on
the footprint.
1.2. The projection of the external Malleolus (B) on
the footprint.
2. Obtain the longitudinal axis of the foot, determined
by:
2.1. The lower point of the rearfoot.
2.2. The position of the first phalange of the
second toe.
3. Obtain the intersection point (C) of the Malleolus
axis and the longitudinal axis of the foot.
Valgus Index = [(0.5*AB-AC)/AB]*100

Criteria:

Valgus Index < 11%: Tendency to rearfoot varus.

11% < Valgus Index < 14%: Normality range.

Valgus Index > 14%: Tendency to rearfoot

valgus.

Image:

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X-Ray
LATERAL VIEW ON LOADED FOOT:

Inclination angle of the Calcaneus

Obtained from:

Lateral view. Loaded foot.

Tools:

X-ray.

Definition:

Angle formed by the support plane (Plane formed by

the lower point of the Calcaneus and the lower point
of the head of the 5th Metatarsal.) and the inclination
axis of the Calcaneus.

Criteria:

Inclination angle of the Calcaneus < 20: Flat

foot.

20 < Inclination angle of the Calcaneus < 30:

Normality range.

Inclination angle of the Calcaneus > 30: Cavus

foot.

Image:

ONLINE TRAINING

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Djian Annonier or medial frame angle

Obtained from:

Lateral view. Loaded foot.

Tools:

X-ray.

Definition:

Angle formed by the following axis:

Criteria:

First longitudinal Metatarsal axis.

Calcaneal axis.

Djian Annonier angle < 115: Cavus foot.

115 < Djian Annonier angle < 135: Normality

range.

Djian Annonier angle > 135: Flat foot.

Image:

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

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Internal Moreau-Costa-Bertani angle

Obtained from:

Lateral view. Loaded foot.

Tools:

X-ray.

Definition:

Angle formed by the following lines:

Criteria:

Image:

ONLINE TRAINING

Line formed from the lower point of the medial

Sesamoid to the lower point of the Talonavicular
joint.

Line formed from the lower point of the

Talonavicular joint to the lower point of the
posterior calcaneal tuberosity.

115 - 125: Normality range.

130: Flatfoot
<115: Cavus foot

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Meary-Tomeno line or Shade line

Obtained from:

Lateral view. Loaded foot.

Tools:

X-ray.

Definition:

Line that passes through the middle of the talus and axis of
first metatarsal bone.

Criteria:

Normal foot: when the projection of the Meary-Tomeno

line or Shade line passes through the axis of the talus,
Navicular, 1st Cuneiform and 1st Metatarsal bone.

Flat foot: when the Meary-Tomeno line or Shade line

does not coincide with the axis of the Navicular, 1st
Cuneiform and 1st Metatarsal. In flat foot this line has a
lower angulation between 1 metatarsal and talus axis.

Cavus foot: when Meary-Tomeno line has an upper

angulation between 1 metatarsal and talus axis.

Image:

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Hibbs angle
Obtained from:

Lateral view. Loaded foot.

Tools:

X-ray.

Definition:

Angle formed by the following lines:

Criteria:

Image:

ONLINE TRAINING

Diafisis axis of the 1st Metatarsal.

Calcaneal axis.

Hibbs angle < 130: Pes cavus.

130 < Hibbs angle < 160: Normality range.

Hibbs angle > 160: Pes Planus.

Module 2 Session 1 __ 23/26

ANTEROPOSTERIOR VIEW ON LOADED FOOT:

Talus-Calcaneus divergence angle

Obtained from:

Lateral view. Loaded foot.

Tools:

X-ray.

Definition:

Angle formed by the anteroposterior angle of the Calcaneus

and the Shade line.

Criteria:

20 - 35: Normality range.

< 20: Flatfoot.

>35: Cavus foot

Image:

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VALIDATION
The use of the proper orthotic solution should provide the following improvements:

Gait analysis

Normal gait. A complete support of the medial zone appears during the gait.
Foot stability is improved.

Baropodometry (Pressure insoles)

Pressures on the medial zone of the calcaneus will be decreased during the
initial heel contact. The initial heel contact is in physiologic varus.
During the mid-stance phase, pressures on the internal longitudinal arch will be
decreased.
Overpressures on the central and medial metatarsals will be improved during
the take-off phase.

ONLINE TRAINING

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BIBLIOGRAPHY
1. J.L. Moreno de la Fuente; Podologa general y biomecnica, Masson (2003)
Barcelona.
2. Thomas C. Michaud D.C. Newton, Massachusetts. Foot Orthoses and other
formas of conservative foot care. Williams & Wilkins (1993). 428 East Preston
Street, Baltimore, Maryland 21202, USA.
3. A.Chevrot; Diagnstico por imagen de las afecciones del pie, Masson (2000)
Barcelona.
4. M. Nez-Samper, L.F. Llanos; Biomecnica, medicina y ciruga del pie. Masson
(2007), 2ed Barcelona.
5. R. Viladot, O.Cohi, S. Clavell; Ortesis y prtesis del aparato locomotor.2.1.
Extremidad inferior; Masson, Barcelona (1987).
6. American Academy of Orthopaedic Surgeons. Atlas of orthotics. Biomechanical
principles and application. The C.V. Mosby Company. ST. Louis, Toronto,
Princeton (1985).
7. Enrique Viosca, MFrancisca Peydro, Antonio Puchol, Carlos Soler, Jaime Prat,
Aleixandre Corts, Javier Snchez, Juan M. Belda, Rubn Lafuente, Raquel
Poveda. Gua de uso y prescripcin de productos ortoprotsicos a medida
Instituto de Biomecnica de Valncia (1993).
8. Ronald L. Valmassy, DPM, MS. Clinical biomechanics of the lower extremities
1996 Mosby- Year Book, Inc.
9. Andr-R. Baehler. Tcnica ortopdica: indicaciones Tomo I Biomecnica
Extremidad inferior. 1999 Masson. Zurich. Ronda General Mitre, 149- Barcelona
(Espaa).
10. Donald Lorimer, Gwen French, Maureen ODonnell, J. Gordon Burrow. Neales
Disorders of the foot. Diagnosis and Management 2002 sixth edition. Churchill
Livingstone.
11. Gerald F. Harris, Peter A. Smith, Richard M. Marks. Foot and ankle motion
analysis. Clinical treatment and technology 2008. Taylor &Francis Group.
12. A. I. Kapandji. Fisiologa articular 5 edicin. Editorial medica Panamericana.
Tomo 2 Miebro inferior. 1998.
13. Kevin A. Kirby, DPM, MS. The medial heel skive tchnique. Improving pronation
control in foot orthoses Journal of the American Podiatric Medical Association.
Vol. 82. N 4, April 1992.
14. Catalina Rojas Benjumea, Carlos Andrs Quiroz Mora. Rehabilitacin y
tratamiento ortesico en pacientes con pie plano www.efisioterapia.net/articulos

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15. Patrick Agnew, DPM, FACFAS, FACFAP Evaluation of the child with ligamentous
laxity Pediatric Podiatry. Vol. 14 N 1. January 1997. Clinics in podiatric
medicine and surgery.
16. C. Revenga- Giertych y M.P. Bulo-Concelln. El pie plano valgo: evolucin de
la huella plantar y factores relacionados Rev. Ortop. Traumatologa. 2005; 49:
271-80.
17. NVOS-Orthobanda Orthopaedic Shoe Technology Book 2 Orthopedie 2002.
ISBN 90-5652-035-0.

ONLINE TRAINING