Ilyanir wrote:

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Ivanm39, here's some information about valgus. Basically Valgus is just the bending of the foot, i.e. pronation caused by flat feet. This bending causes or can cause tenderness, pain, joint damage, etc. as it causes undue pressure to your body. You stated that your entrance exam stated right foot pes valgus (your foot pronated, i.e. was bending to the side because of a foot deformity, flat foot pes planus). I suffer from Bilateral Pes Planus and have severe problems with my feet. They feel hot, sweat, feel like I'm being whacked in the foot with a 2x4 at times, etc. When I stand my feet swell and turn reddish purplish and hurt like hell. I've had surgery on both of my feet, i.e. Tarsal Tunnel Release and am currently rated at 30% for my feet bilaterally plus I have a percentage for the scars caused by the surgery. If your entrance exam only noted that you have one foot effected then you definitely have a claim for the second foot as it wasn't included as having anything wrong when you entered the military. Moreover, you can claim bilateral pes planus if your military service aggravated or caused your flat foot condition to become worse. I know first hand that the combat boots, carrying heavy ruck sacks, running in boots, etc. will cause damage to your feet. Just hang in there bro and stick to your guns. See a podiatrist, get statements from friends, family, co-workers etc. about your flat foot condition and how it effects your daily life. Above all don't take no for an answer. I hope this helps you a little bit.

When the arch ligament stretches or tears, the arch falls. If it falls far enough, the tarsals may begin to shift to the inside or create pronation or a valgus (greater than 90 degree erect) position at the ankle. This can cause problems in the origin area, (the metatarsals) or in the heel. It also may cause pressure on the medial (inner) knee and perhaps the hip and back. It is like pulling the string on a marionette too tight, the result is a kinked mass on one side. The human body is much the same, put too much tension on major muscle groups and the joints kink and yell back.

THE SYMPTOMS

As the ankle shifts inside, you may notice a gap between the foot and the outside wall of slip on shoes. If bad enough, even tie shoes will show this shift. The farther the shift. the more problems that are created.

Pronation or valgus is rated as first, second and third degree, just like burns. First degree is a small amount of medial displacement, usually no pain or chronic problems. You may have a gap in some of your shoes, some extra callous formations (usually at the ball of the foot or out side of the heel), and you may turn your shoes and wear down the outside edge of your heel.

Second degree pronation is simply more rotation to the midline. Some minor leg aches at night, just after you go to sleep may occur. Shoes do turn, and heel wear is worse. Some may complain of arch pain or pressure in the inner knee.

Third degree pronation is a true valgus condition. The rotation is very evident. In some, the talus bones make such a shift to the inside, that the navicular is actually pushed out of position and can be readily seen. In these persons, the shift is great enough that they often look like they have two ankles. Your ankle bone is actually part of your descending tibia and fibula leg bones. They are large areas of muscle attachment that hold your foot on to your leg. The second bone showing is the displaced navicular. This is caused when the heel bone pivots to the inside, allowing the talus above to also shift medial and down, forcing out the navicular.

VALGUS OR PRONATIONa Common Result

Pes Planus / Flat Foot

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- Discussion:
- loss of normal medial longitudinal arch leads to pes planus, which can be flexible or rigid;
- may arise as a consequence of hyper-pronation or from increased eversion of the subtalar joint;
- hence, the calcaneus lies in valgus and external rotation relative to the talus;
- associated midfoot sag may be due dorsal subluxation of the navicular on the talus;
- talonavicular subluxation throughout stance phase is a major biomechanical consequence of the flat foot deformity;
- the lateral column is short in relation to the medial column;
- pediatric population:
- typically infants have a minimal arch and often toddlers have flattening of the long arch, forefoot pronation, & heel valgus
on wt bearing, severity of which is variable (this is especially common in black children);
- ligamentous laxity is apparent, & degree of abnormality in bone-ligament complex probably is determined genetically;
- usually within the first decade, these children spontaneously develop a strong noraml arch;
- references:
- The longitudinal arch. A survey of eight hundred and eighty-two feet in normal children and adults.
Staheli L, Chew D, Corbett M: J Bone Joint Surg 1987;69A:426-428.
- adult population:
- may occur in 20 % of adults, most of which are flexible;
- many people w/ flat foot can walk as comfortably and as easily as others who w/ normal arches as long as there is no heel cord contracture;
- flat feet w/ a concomitant heel cord contracture may limit function;
- there is some evidence that flat feet protect against metatarsal stress frx, but are poor shock absorbers
with regard to the lower back (causing higher incidence of low back pain);
- in contrast, a cavus foot may actually be somewhat protective of stress related low back pain;
- etiology / cause of adult flat foot:
- posterior tibial tendon rupture
- deficiency of the spring ligament complex:
- Morphometric Dimensions of the Calcaneonavicular (Spring) Ligament

- references:
- The longitudinal arch. A survey of eight hundred and eighty-two feet in normal children and adults. Staheli L, Chew D, Corbett M: JBJS 1987;69A:426-428.
- Does arch height affect impact loading at the lower back level in running? M. Ogon MD. Foot and Ankle International. Vol 20. No 4. Apr 1999. p 265.
- how the subtalar joint affects flat feet:
- associated conditions / diff dx:

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- Clinical Manifestations:
- must distinguish betwen flexible flat foot & rigid / spastic flat foot;
- hypermobile foot:
- the suspended foot will regain a normal appearing arch;
- as the patient stands on his toes, the arch will reappear & heel will move out of a valgus position.
- this is a good indirect test for nl subtalar motion;
- forefoot varus:
- once foot is placed in sub-talar neutral position assess whether there is relative forefoot varus (see exam of subtalar joint);
- lateral impingement (sinus tarsi and fibular-calcaneal):
- ref: Talocalcaneal and Subfibular Impingement in Symptomatic Flatfoot in Adults.
- complicating factors:
- heel cord contracture:
- lateral deviation of achilles w/ wt bearing;
- severe achilles contracture is associated with midfoot break down;
- hyperpronation of hindfoot:
- supination of the forefoot which does not correct when hindfoot is reduced;
- everted heel w/ fails to invert w/ toe raise;
- abducted forefoot;

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- Radiographic Analysis:
- standing lateral:
- normally there is a straight line relationship between talus & first metatarsal;
- in flat foot this relationship will be lost & there will be a sag at either the talonavicular or naviculocuneiform joint;
- standing AP:
- degree of heel valgus is important to assess;
- talocalcaneal angle is measured and if > 35 deg, heel valgus is said to be present;
- note the degree of talo-navicular uncoverage / subluxation;
- oblique views to r/o tarsal colatition;
- references:
- Measurements on radiographs of the foot in normal infants and children.
J Bone Joint Surg 1988;70A;411. Vanderwilde R, Staheli LT, Chew DE:

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- Non Operative Treatment:
- flexible flatfoot is generally a benign condition that rarely requires treatment;
- heel cord stretching should be the main emphasis of treatment;
- be sure to supinate the foot while stretching inorder to "lock the midfoot" (avoids worsening midfoot collapse);
- foot orthotics:
- in most cases orthotics will not alter osseous relationships and are ineffective in may patients;
- furthermore, arch supports may actually make the patient's symptoms worse, until a concomitant heel cord contracture is relieved;
- in patients with talonavicular subluxation, consider taking a wt bearing AP of the patients feet with and without the inserts;
- if the talonavicular joint subluxation is not corrected w/ inserts then the inserts are probably not doing their job;
- in some cases, patients with a calcaneovalgus deformity can "normalize their wt bearing pattern" w/ a medial heel wedge;
- children and adolescents:
- many feet improve as the child ages, at least until 5 to 6 yrs old;
- flexible flatfeet are asymmetic for most pts, & its impossible to predict which planovalgus feet will become painful in adulthood;
- hence, most orthopaedists consider their use to be unnecessary in children;
- references:
- Corrective shoes and inserts as treatment for flexible flatfeet in infants and children.
Wenger D, Mauldin D, Speck G, et al: J Bone Joint Surg 1989; 71A: p 800-810.
- The influence of footwear on the prevalence of flat foot. A survey of 2300 children.
- The injury risk associated with pes planus in athletes.
- A Randomized Controlled Trial of Two Types of In-Shoe Orthoses in Children with Flexible Excess Pronation of the Feet

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- Indications for Surgery:
- cerebral palsy:
- equino-valgus foot deformities w/ heel cord contracture in patients w/ CP
will generally tend to have break down of mid-foot and longitudinal arch;
- these patients are best treated w/ tendo-achilles lengthening (w/ severe
contracture) or a sub-talar fusion before mid-foot break down occurs;
- once mid-foot break down occurs, a triple arthrodesis is required;
- painful rigid flatfoot:
- small number of flexible flatfeet do not correct w/ growth & will become rigid due to adaptive changes occur;
- painful rigid flat foot will require triple arthrodesis
- painful flexible flatfoot:
- in this situation, it is important to determine the anatomic cause of the pain;
- as noted by JTC Lau and TR Daniels, a tarsal tunnel release w/ a concomitant pes planus may have the effect
of increasing posterior tibial nerve tension, which may explain the high rate of poor surgical results;
- in the same study, distraction calcaneo-cuboid arthrodesis reduced nerve tension;
- reference:
- Effects of tarsal tunnel release and stabilization procedures on tibial nerve tension in a surgically created pes planus foot.
JTC Lau and TR Daniels. Foot and Ankle Internation. Vol 19. No 11. Nov 1998. p 770.

- Contra-Indications for Surgery:
- hyper-mobile joints (such as w/ Marfan's, Ehler's Danlos, Down's);
- in adults, if feet are asymptomatic, surgery is almost never indicated;

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- Operative Treatment:
- medial os calcis sliding osteotomy or opening wedge osteotomy of lateral calcaneus may realign hindfoot & relieve
symptoms w/o producing loss of motion associated w/ fusions;
- FDL Transfer: (in the case of PT rupture);
- medial calcaneal sliding osteotomy:
- lateral column lengthening:
- references:
- Effect of variation in calcaneocuboid fusion technique on kinematics of the normal hindfoot. A. Sands et al. FAI Vol 19. No 1. Jan 1998. p 19.
- Selective tarsal arthrodesis: An in vitro analysis of the effect on foot motion. H Gellman et al. Foot and Ankle. Vol 8. 1987. p 127-133.
- Calcaneo-valgus deformity. D. Evans. JBJS. Vol 57-B. 1975. p 270-278.
- Early Graft Failure in Lateral Column Lengthening.
- Evans calcaneal lengthening procedure for spastic flexible flatfoot in 32 patients (46 feet) with a followup of 3 to 9 years.
- A Comparison of Lateral Column Lengthening and Medial Translational Osteotomy of the Calcaneus for Recon of Adult Acquired Flatfoot
- medial cuneiform osteotomy:
- may be indicated w/ fixed forefoot supination;
- medial soft tissue reconstruction:
- drill holes are made in the medial malleolus and the medial cuneiform thru which is passed a
free tendon graft (using the extensor digitorum longus tendon);
- ref: Reconstruction operations for acquired flatfoot: biomechanical evaluation.
HB Kitaoka MD et al. Foot and Ankle International. Vol 19. No 4. Apr 1998 p 203.
- achilles tendon lengthening:
- may be indicated for intractable equinus deformity, when other reconstructive procedures are to be performed as well;
- triple arthrodesis:
- indicated only when there is severe midfoot collapse;

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