Planovalgus deformity

WHAT IS PLANOVALGUS DEFORMITY?

The planovalgus deformity is one of the most common foot disorders that must be clarified in the orthopaedic foot consultation. Planovalgus deformity is characterised by a malposition of the arch of the foot and the heel, resulting in a partial or complete loss of the longitudinal arch. In contrast to adults, paediatric planovalgus deformity is a natural stage of foot development. A major challenge for the foot surgeon is therefore to recognise the boundary between an age-appropriate normal foot position and a genuine pathology.

HOW COMMON IS PLANOVALGUS DEFORMITY?

The overall incidence of adult-onset is 3 to 19% and is not uniform worldwide. This is certainly also due to the blurred diagnostic criteria or a high proportion of completely asymptomatic sufferers. Certain ethnic groups, such as the indigenous people of New Zealand, appear to be affected by this „deformity“ more frequently than their compatriots. The typical age of first diagnosis and symptoms is around 40 years. Women are more frequently affected by this foot deformity. Certain secondary diagnoses such as obesity and diabetes mellitus may increase the risk of developing symptomatic planovalgus deformity.

HOW DOES A PLANOVALGUS FOOT DEVELOP?

The most common cause is probably overloading and functional impairment of the tibialis posterior tendon. It is not always easy to distinguish whether this tendon is the cause or consequence of the disease, but its importance for further malalignment is generally recognised. Partial ruptures of the tendon can lead to a loss of strength and ultimately to malalignment of the foot. Acute injuries such as direct trauma to the tendon (traumatic rupture, tendon dislocation) are rare. Structural changes to the lower leg and foot, either congenital or acquired, can also favour the development of the deformity. Other, rarer causes include growth disorders (tarsal coalitions), chronic inflammatory processes (e.g. sero-negative spondyloarthritis) and systemic diseases such as gout or hyperlipidaemia.

HOW CAN A PLANOVALGUS DEFORMITY BE CATEGORISED?

The most common classification worldwide refers to its most common cause, dysfunction of the tibialis posterior tendon, and is based on Johnson/Strom. The early stages refer to flexible, i.e. retractable malalignments, which can in principle be treated by preserving the joint (without stiffening). From stage III, an advanced deformity, we speak of rigid deformities, which can generally only be treated with partial/fixed joints.

HOW DO COMPLAINTS THAT ARISE IN THE CONTEXT OF A PLANOVALGUS DEFORMITY MANIFEST THEMSELVES?

Affected patients often report fatigue during/after prolonged standing and walking and complain of pain that is typically localised in the area near the insertion of the posticus tendon, i.e. from the inner ankle to the midfoot. In the case of more severe deformities, pain can also occur in the area of the outer edge of the foot/outer ankle due to impingement at the side of the lower ankle joint. If there is also joint wear and tear (osteoarthritis) due to the malalignment, pain in the affected joints is to be expected sooner or later.

HOW DOES THE TYPICAL PLANOVALGUS DEFORMITY SHOW UP IN THE CLINICAL EXAMINATION?

The clinical examination with inspection, palpation and functional testing should always precede diagnostic imaging.

Inspection usually reveals a reduced, sometimes collapsed longitudinal arch. A simple test with the examiner’s index finger can help to assess the degree of severity („finger-o-meter“). If the doctor performs a manual examination, the posticus tendon close to the attachment is often painful. Accompanying shortening and contractures of the calf muscles must be assessed. The so-called toe tip test should help to differentiate between rigid and flexible misalignments.

If the heel straightens from the hindfoot bend in the (one-legged) tiptoe stance, this is a flexible deformity. If it is no longer possible to actively stand on tiptoe and the heel can no longer be brought out of the kink, this is a rigid deformity. In addition, attention should be paid to a deformation of the forefoot during the clinical examination. This should be taken into account when planning treatment.

WHICH IMAGING EXAMINATIONS ARE NECESSARY FOR CLARIFICATION?

An essential part of the diagnostic imaging is the X-ray of the standing foot in two planes. A variety of parameters are determined in the X-ray image in order to assess the extent of the deformity.

The MRI examination can provide helpful information about the condition of the tibialis posterior tendon (tendinosis, rupture, peritendinitis, etc.) or show the condition of the ankles without superimposition.

The CT scan is not an integral part of the diagnosis, but can be used for certain issues such as tarsal coalitions.

HOW CAN THE DEFOMITY WITH EXISTING PAIN BE TREATED?

In stage I (tenosynovitis of the posticus tendon without malalignment), conservative measures such as targeted manual therapy exercises (e.g. spiral dynamics) and orthopaedic treatment (e.g. custom-made orthopaedic insoles) are the main treatment options.

In the next stage, conservative therapy is usually no longer sufficient and orthotics alone are usually no longer effective. Patients often report a large number of failed orthotic treatments. Surgery is available here as a promising alternative.

WHAT OPTIONS ARE THERE FOR OPERATING ON THE DEFORMITY?

Whenever possible, joint-preserving operations should be performed that involve a combination of different soft tissue and bony procedures. The „workhorse“ of the therapy is the combination of calcaneus surgery (bony) and a flexor tendon transfer.

Surgical technique: In the so-called MDO (Medialising Deviation Osteotomy), the calcaneus is cut through and displaced via an incision on the outside of the heel, thereby moving the point of impact of the calcaneus inwards (and possibly downwards) in order to reposition it under the longitudinal axis of the tibia. The usually additional tendon transfer supports the weakened tibialis posterior tendon and acts as a new motor for the corrected deformity. Further procedures can be added depending on the accompanying deformity.

At an advanced stage, a combination of partial/stiffening of different joints is the treatment of choice. The principle is that as few joints as possible should be stiffened in order to maintain residual mobility.

WIE SIEHT DIE NACHBEHANDLUNG AUS?

It must be mentioned that operations for the deformity are particularly complex for the patient. As a rule, partial weight-bearing of 10 kg should be maintained for the first 6 weeks after the operation. This is followed by an X-ray check and further weight-bearing is determined. Full weight-bearing is usually possible after 12 weeks and it is also possible to drive independently again. It can take up to 6 months before the foot feels comfortable enough to walk longer distances and hike. Overall, however, very good results can then be expected.

Studies show that the majority of patients would have the operation again.

YOUR SPECIALIST FOR PLANOVALGUS DEFORMITY AND OTHER SYMPTOMS

„Numerous deformities and wear and tear disorders of the foot and ankle can also be treated excellently using minimally invasive techniques.“

ADVICE AND CONTACT FOR QUESTIONS ABOUT KNICKFEET AND FLAT FEET

Do you have questions about treatment and therapy for fallen arches? Our foot specialists will be happy to provide you with detailed information and advice in a personal consultation. Simply make an appointment. We look forward to seeing you.

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Planovalgus deformity

WHAT IS PLANOVALGUS DEFORMITY?

HOW COMMON IS PLANOVALGUS DEFORMITY?

HOW DOES A PLANOVALGUS FOOT DEVELOP?

HOW CAN A PLANOVALGUS DEFORMITY BE CATEGORISED?

HOW DO COMPLAINTS THAT ARISE IN THE CONTEXT OF A PLANOVALGUS DEFORMITY MANIFEST THEMSELVES?

HOW DOES THE TYPICAL PLANOVALGUS DEFORMITY SHOW UP IN THE CLINICAL EXAMINATION?

WHICH IMAGING EXAMINATIONS ARE NECESSARY FOR CLARIFICATION?

HOW CAN THE DEFOMITY WITH EXISTING PAIN BE TREATED?

WHAT OPTIONS ARE THERE FOR OPERATING ON THE DEFORMITY?

WIE SIEHT DIE NACHBEHANDLUNG AUS?

YOUR SPECIALIST FOR PLANOVALGUS DEFORMITY AND OTHER SYMPTOMS

Prof. Dr. Norbert Harrasser*

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