import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # Flatfoot Examination Adult flatfoot examination requires systematic assessment of the posterior tibial tendon, hindfoot alignment, and flexibility of the deformity. Examiners expect you to perform the single heel raise test, too-many-toes sign, and differentiate flexible from rigid flatfoot. ## Quick Reference One-Pager ## Pathophysiology **Anatomy:** - PTT inserts on navicular, cuneiforms, and MT 2-4 bases - Primary dynamic stabilizer of medial arch - Inverts hindfoot and locks transverse tarsal joints **Pathophysiology Sequence:** 1. PTT degeneration/inflammation 2. PTT elongation/rupture 3. Spring ligament failure 4. Hindfoot valgus develops 5. Forefoot abduction (talonavicular subluxation) 6. Lateral structures (sinus tarsi) impinge 7. Subtalar arthritis (rigid) 8. Ankle valgus (end-stage) **Risk Factors:** - Female, middle-aged, obesity - Hypertension, diabetes - Inflammatory arthritis - Steroid injections near tendon **Understanding PTT Failure:** When PTT fails: - Peroneus brevis is unopposed → Hindfoot everts (valgus) - Transverse tarsal joints unlock → Forefoot abducts - Spring ligament stretches → Talar head drops medially - Weight shifts lateral → Sinus tarsi pain This explains all the clinical findings! ## Observation **From Behind:** - Hindfoot alignment (valgus heel) - "Too-many-toes sign" (abducted forefoot) - Achilles tendon alignment (lateral bow) **From Medial Side:** - Medial arch height (collapsed) - Talar head prominence (medial) - Navicular drop **From Front:** - Forefoot supination (compensatory) - Callosity pattern **From Lateral Side:** - Midfoot sag - Rocker-bottom appearance (severe) ## Palpation **Course of PTT:** - Posterior to medial malleolus - Along medial calcaneus - To navicular insertion **Palpation Findings:** - Tenderness along tendon course - Swelling (tenosynovitis) - Thickening or gap (rupture) - Navicular insertion tenderness **Compare with Normal Side:** - Tendon should be easily palpable - Crepitus with movement ## Specific Tests **Interpreting Single Heel Raise:** - **Normal**: Heel inverts, can do 10+ repetitions - **Stage I PTTD**: Can do but painful - **Stage II PTTD**: Weak, few reps, heel doesn't invert fully - **Stage III-IV**: Cannot do at all (rigid subtalar or ankle) The heel MUST be observed from behind - inversion is the key finding! ## Flexibility Assessment **Flexible Flatfoot:** - Arch present non-weight-bearing - Arch collapses with weight-bearing - Jack test positive (arch reconstitutes) - Subtalar motion preserved - Hindfoot valgus corrects when on tiptoes **Rigid Flatfoot:** - Arch absent even non-weight-bearing - Jack test negative - Subtalar motion restricted - Hindfoot valgus doesn't correct - Often painful (arthritis) **Assessment Technique:** - Manual correction of hindfoot valgus - Subtalar ROM (inversion/eversion) - Talonavicular mobility - Midtarsal joint assessment ## Staging (Johnson-Strom Modified) **Staging Determines Surgery:** - **Flexible (I-II)**: Soft tissue reconstruction + osteotomy - **Rigid (III)**: Fusion (subtalar ± triple) - **Ankle involved (IV)**: Include ankle in fusion Flexibility testing is therefore CRITICAL for surgical planning! ## Associated Assessment **Ankle:** - Deltoid ligament integrity - Lateral ankle pain (sinus tarsi impingement) - Ankle ROM (often tight in equinus) **Forefoot:** - First ray position (elevatus common) - Lesser toe deformities - Callus pattern **Neurovascular:** - Pulses (atherosclerosis common in risk group) - Sensation (diabetes association) - Tarsal tunnel symptoms (nerve stretch) **Contralateral Side:** - Often bilateral - Compare for staging ## Differential Diagnosis ## Summary Presentation ## Examination Sequence 1. **Observe standing**: Hindfoot valgus, too-many-toes, arch collapse 2. **Observe gait**: Antalgic, toeing out 3. **Palpate PTT**: Tenderness, swelling along course 4. **Single heel raise**: Function and heel inversion 5. **Jack test**: Flexibility (windlass mechanism) 6. **Manual correction**: Hindfoot valgus correctability 7. **Silfverskiöld**: Gastrocnemius tightness 8. **Subtalar motion**: Inversion/eversion (rigid vs flexible) 9. **Ankle**: ROM, deltoid, valgus tilt 10. **Neurovascular**: Pulses, sensation ## Examiner Tips