Flattening in childrenFlat feet in children - a change in the configuration of the skeleton of the foot, associated with the flattening of its arches and leading to a violation of the mechanics of walking. Flattening in children is manifested by fatigue, pain in the legs during movement and static load, edema and deformity of the foot, change in gait, difficulty walking. The diagnosis of flat feet in children is established on the basis of clinical examination, data of planktonography, podometry and radiography of the feet. For the treatment of flat feet in children conservative methods are used( massage, therapeutic gymnastics, physiotherapy, application of plaster dressings and orthoses);operative intervention is carried out in extreme cases.
Flat feet in children
Flat feet in children - the most common orthopedic pathology in pediatrics, manifested by a decrease in the height of the arches of the foot. Flattening can be detected in the child from birth( in 3% of cases);to 2-4 years it is observed in 24-32% of children, by 7 years - in 40%, by 12 years - in 50% of adolescents.
Active formation of the arches of the foot in children occurs gradually, with the appearance and increase in the load on the legs. The critical moment in the development of flat feet is the age period from 8 months to 1.5 years, when the child begins to get up and learn to walk. At an early age, all children have a physiological flat foot, due to age-related anatomical and functional features: the cartilaginous structure of bones, more elastic and elongated ligaments, weak muscles. With the right development with increasing strength and endurance of muscles, this condition in children independently normalizes to 5-6 years. With certain violations in children, flat feet develop, leading to a sharp decrease in the damping capacity of the foot, an increase in the load on other elements of the musculoskeletal system with damage to the knee and hip joints, deformation of the spine, disruption of the internal organs.
Classification of flatfoot in children
The foot has longitudinal and transverse arches supporting muscles and ligaments, providing balance of the body, distribution and mitigation of shock load during walking, running and jumping, and also increasing endurance to the axial load. According to the anatomical sign in orthopedics, longitudinal, transverse and combined flat feet are distinguished. Children often encounter longitudinal flat feet with a flattening of the longitudinal arch and an elongation of the foot that touches the floor with the entire surface of the sole. With transverse flat feet in children, the length of the foot decreases, its front section rests on the heads of all metatarsal bones.
Flattening in children can be congenital and acquired. The congenital form is quite rare and is associated with malformations of the bone structures and the musculoskeletal apparatus of the foot. Acquired platypodia in children depending on their origin can be static, traumatic, rachitic, paralytic. The most common static flatfoot is more common in school-age children when there is a discrepancy between static and dynamic load on the foot and muscle tone.
Causes of flatfoot in children
Flat feet in children can develop for various reasons. Congenital flat feet in children is observed in utero underdevelopment of the bones, muscles, ligaments and tendons of the shins and feet. Acquired flat feet in children also develops against the background of congenital insufficiency of connective tissue and can be combined with an additional chord in the heart, bend of the gallbladder, myopia, etc. In the formation of flat feet in children, the hereditary factor - the presence of this pathology in close relatives - is of great importance.
Flattening in children can be caused by the weakness of the musculoskeletal foot apparatus that does not withstand heavy loads;defeat of the musculoskeletal system in rickets;incorrectly fused fractures of the ankles, metatarsals, heel and talus bones;paralysis or paresis of the muscles of the lower leg and foot( including after poliomyelitis);neurological pathology( encephalopathy).
The appearance of static flat feet in children is promoted by wearing incorrectly picked up shoes( cramped, dissimilar, on a thick sole), overweight and obesity, prolonged continuous walking or standing. Often flat feet develop in children with flat-foot deformities of the feet.
Symptoms of flat feet in children
In most cases of congenital flatfoot, one foot is affected in children, which looks like a rocking chair or a "paperweight" with a convex sole and a flattened, even concave back. There is heel instigation of the foot, a sharp pronation with the removal of the fingers outwards. With the advent of static load, congenital flat feet are aggravated and fixed.
In children 6-7 years of age, flat feet are manifested by rapid fatigue when walking and standing, by trampling the shoe along the inner edge of the sole and heel. Clinical symptoms of acquired flat feet in children are aching pains in the foot area, which increase after a long stay on the legs;puffiness of the feet in the evening, fatigue when walking.
There are three degrees of longitudinal flat feet in children, determined by the degree of deformation of the foot. At I degree, the height of the arch of the foot is 25-35 mm, there is no visible deformation of the foot. At II degree - the height of the arch is from 25 to 17 mm, flattening of the foot is visible to the naked eye;Platypodia in children is manifested by an increase in pain in the foot, ankle and calf muscles, difficulty walking. The shape of the foot changes - its length increases, the middle part widens, the gait becomes heavy and clumsy;children have a rapid overall fatigue. Flattening of the third degree is characterized by a pronounced deformation of the foot, a decrease in the height of the arch less than 17 mm, constant pain in the legs and lower back, headaches, the impossibility of walking in ordinary shoes.
Flattening causes the curvature of the toes of the foot, the appearance of calluses, the formation of disorders in the child's posture( scoliosis) and spine diseases( osteochondrosis, herniation of intervertebral discs), deforming arthrosis, meniscal inflammation, etc.
Diagnosis of flatfoot in children
children up to 5-6 years of age are quite problematic. The diagnosis of severe flat feet in children can be made by a pediatric orthopedic surgeon during a clinical examination that allows to detect changes in the length, width and volume of foot movements, a violation of the state of its arches, and the wear of footwear.
Objective methods of assessing flat feet in older children are planography - obtaining a footprint of a footprint on paper and a subgrade - measuring the "sub-metric index" of the arch of the foot. Clarify the diagnosis of flat feet in children I help the results of radiography of the feet with the load performed in 2 projections.
Flat feet treatment in children
Flattening in children is a progressive disease, and the earlier treatment is started, the more effective the results. The treatment of congenital flat feet begins with the first weeks of the child's life, which allows eliminating all the components of the foot deformity. With congenital flat feet, children undergo special therapeutic exercises, massage the muscles of the foot and lower leg;the foot is held in the correct position by means of bandaging, the imposition of stage plaster casts, and night orthoses( from the age of 6 months).With aggravation of flat feet in children, a subartar arthroesis is performed.
Treatment of static flat feet in children, aimed at strengthening the musculoskeletal apparatus of the foot, includes massage, physiotherapy and exercise therapy. Young children are excluded from soft shoes( felt boots, rubber boots, Czechs);It is recommended to wear shoes with a firm sole and a small heel, which fix the ankles well. When flat feet in older children shows wearing orthopedic shoes with a foot-instep, raising the lowered arch and returning the foot to the correct position.
To eliminate flat feet in children, hydromassage, contrasting foot baths, paraffin, ozocerite and mud applications on the foot area, magnetotherapy contribute to the elimination of flat feet. In the absence of the correction effect, gypsum dressings and longi are used;in severe cases of combined flatfoot surgery is possible on the bones and soft tissues of the foot and lower leg. The optimal age for surgical treatment of flat feet in children is 8-12 years.
Prognosis and prophylaxis of flatfoot in children
Weak and moderately pronounced flatness in children with timely correction is completely curable;The neglected cases are difficult to correct. In the absence of treatment, flat feet in children leads to severe deformation of the foot, joints and spine.
The prevention of flat feet in children is the wearing of properly matched shoes;physical education, game sports( basketball, football) and swimming;walking barefoot on uneven ground, sand, pebbles;normalization of calcium-phosphorus metabolism;control of body weight.
Transverse platypodia is a widespread pathology in which there is a transverse spreading of the foot and a deviation of the 1st finger outward. The main cause of transverse flatfoot is the failure of the ligamentous apparatus of the foot. Along with the external deformation, it is manifested by pain in the feet, pain and burning in the muscles of the feet and lower legs after physical exertion. The diagnosis is made on the basis of radiography. Symptomatic conservative therapy is performed, with severe deformation, corrective operations are performed.
Transverse platypodia - a pathological condition in which the forefoot stops flattening, and I finger deviates to the outside. Pathology is widespread, women suffer about 20 times more often than men. It is usually found in middle-aged and elderly women, less common in men( usually elderly people), in some cases found in children and adolescents. In traumatology and orthopedics, there is often a combination of transverse and longitudinal flat feet - combined flat feet.
Usually accompanied by more or less severe pain syndrome, weight in the feet and rapid fatigue when walking. Over time, there is stiffness of metatarsophalangeal joints, progressive deformations in the region of the first and second fingers. The reason for going to the doctor, along with the pains, often becomes a pronounced cosmetic defect and problems in the selection of comfortable shoes. Treatment of transverse flat feet is performed by traumatologists and orthopedists.
Causes and mechanism of transverse flatfoot development
Transverse platypodia is a polyetiological disease that occurs under the influence of various factors, including uncomfortable narrow shoes, high heels, long stay on legs, excess weight, previous foot traumas, etc. However, the main reasonthe formation of transverse flatfoot is the inherent weakness of the ligamentous apparatus of the feet. At present, this pathology is considered as an irreversible deformation, which can not be corrected by conservative methods, since there are no medications or orthopedic adaptations that can affect the restoration of tonus and strength of connective tissue formation of the foot.
Normally metatarsal bones are held in anatomically correct position, thanks to the interosseous fascia and the plantar aponeurosis. With the weakness of these connective tissue structures in 30% of cases, all the bones of the metatarsal are diverging in a fan-like manner. In 27% of cases, I deviate from the metatarsal bone in the medial aspect, and the remaining metatarsal bones retain their normal position. In 5-6% of cases the diameter of the foot increases due to the deviation of V and IV metatarsal bones. In other cases, combinations of these options are observed.
The deviation of metatarsal bones is not the only pathological change that occurs with transverse flatfoot. I metatarsal bone often turns around its axis and rises. There is a redistribution of the load: I metatarsophalangeal joint becomes inferior, and the external parts of the foot are constantly suffering from overload. Due to the change in normal relationships between the elements of the foot and the traction of the muscles, the toe of the foot "leaves" outside. I metatarsophalangeal joint is deformed.
A "bone" is formed on the inner surface of the foot, which can represent both an exostosis( bone-cartilaginous growth), and a combination of exostosis with the bulging curved I metatarsophalangeal joint. Because of the excessive pressure of the shoe on the metatarsal bone in the joint area, bursitis occurs, accompanied by local edema and reddening of the skin. Arthrosis of the metatarsophalangeal joint arises, which causes an increase in the pain syndrome. The amount of movement in the joint is reduced.
Curved I finger "goes" on the 2nd finger. Over time, hammer-shaped deformation II is often formed, more rarely - II-III fingers, on the plantar surface are formed napotypes. Plyusnefalangovye joints "go" into a state of subluxation. All of the above causes intense pain, creates severe discomfort when wearing ordinary, and sometimes - orthopedic shoes, leads to a forced limitation of mobility and ability to work.
Symptoms of transverse flatfoot
Patients with transverse flatfoot complain of aching, pulling, stitching or burning pain in the feet, mainly in the area of I-II metatarsophalangeal joints. The pains intensify after a prolonged stay on the legs, can be accompanied by a feeling of heaviness in the feet and a burning sensation in the muscles. By the evening, there may be swelling of the feet and the area of the ankles. Patients report severe difficulties in walking on high heels, as well as problems in choosing shoes - the foot becomes too wide and does not fit into standard shoes.
Visually defined valgus deformation of the 1st finger( Hallux valgus).The forefoot is dilated. In advanced cases, a hammer-shaped curvature of the II-III fingers is revealed. The skin in the region of the I metatarsophalangeal joint is thickened, hyperemic. On the internal and plantar surface in the forefoot of the foot are visible on the ground and calloused. The volume of movements in metatarsophalangeal joints is limited. With palpation, pain is possible.
Diagnosis of transverse flatfoot
The diagnosis of transverse flatfoot is made based on external examination data and the results of the radiograph of the foot. To obtain a complete picture of the disease, usually X-rays of I, II and III plus-nefalangeal joints are prescribed. In the process of describing the images, the radiologist assesses the severity of the valgus deformation of the 1st finger, taking into account the angle between the first finger and the metatarsal II and the angle between the I and II metatarsal bones. There are three degrees of deformation:
- 1 degree - the angle between the 1st finger and the II metatarsal bone does not exceed 25 degrees, the angle between the I and II metatarsal bones does not exceed 12 degrees.
- 2 degree - the angle between the first finger and the II metatarsal bone does not exceed 35 degrees, the angle between the I and II metatarsal bones does not exceed 18 degrees.
- 3 degree - the angle between the 1st finger and the II metatarsal bone exceeds 35 degrees, the angle between the I and II metatarsal bones exceeds 18 degrees.
In addition, when studying the radiographs pay attention to the presence of arthrosis, which is evidenced by deformation of the articulation site, narrowing of the joint gap, osteosclerosis of the subchondral zone and marginal proliferation. If necessary, for a detailed study of dense structures, the patient's feet are directed to CT scans, to assess the state of soft tissue - on MRI.In the presence of concomitant pathology from the nervous or venous system, appoint a phlebologist and neurologist.
Treatment of transverse flatfoot
Tactics of treatment are determined depending on the severity of the pathology, the intensity of the pain syndrome and cosmetic needs of the patient. It is worth noting that modern medicine does not know the non-surgical ways of eliminating the deformity of the I metatarsophalangeal joint, and all the proposals to "remove the stone without surgery" are just advertising stunts. Conservative therapy of transverse flatfoot is aimed at reducing pain and slowing the progression of the disease.
In the early stages, patients are advised to wear interdigital ridges and individual orthopedic insoles. In severe strains, orthopedic footwear is manufactured according to individual measures in accordance with the recommendations of an orthopedic physician. In addition, massage, foot baths, a special set of exercises for strengthening the muscles and ligaments of the foot, as well as physiotherapeutic procedures: magnetotherapy, UHF, electrophoresis with trimecaine or novocaine, phonophoresis with hydrocortisone, inductothermy, paraffin and ozocerite. For pain and signs of inflammation, recommend NSAIDs of local and general action.
Operations are performed with severe deformities of the foot and intense pain syndrome. The cause for surgical intervention in young women is often a cosmetic defect with moderately pronounced valgus deformation of the 1st finger. Depending on the features of the pathology, surgical interventions on soft tissues, on the bones, as well as combined interventions on soft tissues and bones are used. Treatment is carried out after the necessary examination, in a planned manner, in conditions of orthopedic or traumatology department.
In soft tissue operations, the tendons are cut or moved to restore the uniformity of the traction of the muscles that divert and lead the finger. Among the palliative interventions that eliminate external deformities but do not affect the vicious position of the metatarsal I include the excision of the subcutaneous sac and exostosis in the region of the I metatarsophalangeal joint. Such operations can reduce the cosmetic defect and facilitate the use of standard footwear, but over time their effect often disappears due to further progression of deformation.
In order to eliminate the deviation of I metatarsal bone to the inside, Scarf osteotomy or chevron osteotomy is currently the usual procedure, during which the orthopedist removes a bone fragment and restores its anatomically correct position. After surgery for 6 weeks, use special orthoses. In the future, the patient is recommended not to overload the foot, wear comfortable wide shoes, do self-massage and perform special exercises to strengthen the muscles of the foot.
Treatment of transverse flatfoot: surgical treatment, LUTS, massage, orthopedic insoles.
The question of the treatment of transverse flatfoot is one of the most frequently discussed questions in orthopedics, as this pathology affects both children and adults, and the process starts always leads to joint and spinal diseases, so it is so important to develop a comprehensive treatment plan for this disease. For each patient, this plan will be individual, depending on the risk factors( obesity, congenital connective tissue pathology, the profession associated with prolonged stay on the legs) and the presence of concomitant pathology.
Methods for determining flatfoot
When examining the foot, attention is drawn to its expansion and flattening. The thumb is deflected outwards. On the thumb is formed a "bone", the second and third fingers are hammer-shaped deformed.
- quickly get tired of the legs after moving or after work associated with prolonged standing.
- by the evening the legs swell, "get heavy" and hurt.
- when examining the shoe - the heel is flat on the inside.
- stops become wider, and favorite shoes - narrow and tight.
- pain spreads from the foot above to the knee and hip joint, sometimes rendered into the spine and combined with headaches.
All these symptoms and complaints in the complex are an indication for a more thorough examination.
Diagnosis of flatfoot can be done in a medical institution and at home on their own. How to determine flat feet at home? To do this, there is a fairly simple method. It is necessary to smear the feet with a fat cream and stand on a white sheet of paper directly with support on the entire foot. Now it remains to estimate the imprint. Normally, the notch on the inner edge in the middle of the foot should occupy slightly more than half the foot. If it occupies almost the entire foot or vice versa, too much space, then one can think of flat feet. This method is called platnography. Doctors use Lugol's solution as a dye.
At home, you can also calculate the sub-metric index( the sub-metric method of Frinland).To do this, measure the height and length of the foot. The height of the foot is the distance from the plantar surface to the upper edge of the scaphoid bone. The length of the foot is the distance from the tip of the thumb to the edge of the heel. The height of the foot is multiplied by one hundred and divided by the length. Normally, this indicator should not exceed the range of 29 -31.With a sub-metric index of 27-29, flat feet are spoken of.
Confirm diagnosis by X-ray examination of both feet in a straight and lateral projection and under load. Then, based on the analysis of the radiograph, the severity of the changes is determined.
Video "Transverse Plain Foot"
How to treat the flatfoot
Straighten the foot completely only in childhood, when the bones are not yet strong, and the ligament is quite plastic. But up to five to six years to talk about flatfoot early, since the pediatric foot may seem flat due to the fat pad, performing a protective function in relation to the bone base. Therefore, all children with a preventive goal should be examined by an orthopedist once a year.
Treatment of flat feet usually begins with conservative methods, which include massage, physiotherapy exercises and special relaxing foot baths. Orthopedic shoes or insoles are of particular importance.
Foot and foot massage with flatfoot removes fatigue, stimulates blood circulation and reduces swelling. Basic tricks:
- stroking the soles with the back of the brush;
- rubbing the pads of the fingers, performing circular motions;
- rubbing with the fist, while slightly pressing on the foot;
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Basic principles of exercise therapy
When preparing a complex for patients with flat feet, the doctor usually uses the basic exercises for breeding - mixing, flexing - extension, sliding, performing a variety of moves. All these exercises contribute to strengthening the arch of the feet and maintaining the tone of the muscles of the feet.
To remove tension from the muscles of the feet apply baths with decoctions of lime, chamomile, plantain or with sea salt, as well as with aromatic oils( lavender, rose).The water temperature should not exceed 37 degrees.
Orthopedic footwear, inlays and insoles
For the prevention of flatfoot and with a small degree of deformity of the foot, special tabs and insole are used. They are sold in specialized stores or made to order. In advanced cases, wearing orthopedic footwear is appointed, which is always made strictly individually, to order. Such shoes are made of high quality materials and help addictive feet to the right position.
If nothing helps
If the conservative measures are ineffective, usually in the adult age corrective operations on the foot are performed to eliminate flat feet.
Transverse Platypodia: Surgical Treatment
To date, orthopedics has more than 300 methods of surgical correction of transverse flatfoot, the main advantage of which is the absence of relapses. The essence of all interventions with flatfoot is reduced to restoring the correct anatomical shape of the foot due to correction of the transverse arch and changing the angle between the bones of the foot. The choice of technique depends mainly on the severity of the changes and the presence of concomitant deformation of the toes. Surgery is performed under general or spinal anesthesia. After the operation, special orthopedic footwear is prescribed, which allows you to get up on the feet the day after the operation.
Orthopedic insoles for transverse flat feet
Maximum shock absorption during the foot - this is the main characteristic of the correctly selected orthopedic insole. In this case, such an insole should exactly match the size of the foot of the patient and the footwear into which it is embedded. It absorbs a static and dynamic load on the feet and indirectly restores blood flow. In children, the orthopedic insole contributes to the correct formation of the arches of the feet. Many parents buy their children shoes with orthopedic insoles for prevention.
For fashionable modern women, more often men suffering from various deformities of the feet, special semi-insole are designed - insteps for model shoes with high heels and for shoes with low heels, as well as special insole shoes for closed shoes.
All insoles should be selected only with a specialist who can advise the most optimal option.
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Gymnastics with flat feet
LFK with flat feet is the main method of correcting and correcting flat feet. Performing these simple exercises can be an adult and a child under the supervision of parents. Exemplary set of exercises:
- Grasping the ball with stops and lifting.
- Turning stops clockwise and counterclockwise.
- Sliding feet with your fingers.
- Rolling gymnastic stick.
- Skating gymnastic hoop with toes.
- With your toes grab and lift small objects( pencil, sponge)
- Flexion and extension of fingers.
- Rolling from the socks to the outer edge of the foot and back in the standing position.
- Walking on sand barefoot.
Begin training with five to six exercises, and after 10 days begin to add one exercise. The whole lesson should take about 20 minutes. Perform gymnastics for a better effect should be twice a day.
Video "Physiotherapy with flat feet"
In addition, it is useful for adults and children on a warm summer day after rain to mix dirt and bare feet and walk around in puddles barefoot.
Diagnostics of the flatfoot
The modern variety of orthopedic products for the foot and the transition of most of the services to the paid sphere has led to a certain degree to a decrease in the qualification of specialists offering services in the selection of orthopedic products and the manufacture of individual stekle orthoses.
Technical progress and, in particular, computer technologies have brought opportunities in detailed diagnosis and increased visibility of the data. Nevertheless, the diagnosis should be made only after a general examination of the patient. Technical equipment should not overshadow the patient's clinical examination. Particular attention should be paid to areas that cause the appearance of symptoms and individual signs of the disease during clinical examination. Only after the installation of a preliminary clinical diagnosis the doctor prescribes additional methods of research, the purpose of which is to detail and confirm the diagnosis, or to refute it.
"Some doctors, blinded by the availability of amazing equipment and equipment, tend to dispense with the necessary clinical examination of the patient;this development of clinical medicine can not be considered progressive - rather, it is a step backward than forward. "(V.O.Marks, 1978, p. - 5).
But, nevertheless, today in everyday clinical practice one has to face such a phenomenon as the appointment of one newfangled study. As a result of the detailed medical and technical conclusion received from the device, an attempt is made to construct a diagnosis that often does not correspond to clinical and other laboratory data.
So, for example, in orthopedic salons for the production of "individual" stele orthoses began to apply data from the footbridge( "Footscan", etc.)( Fig. 1).
Fig.1.An example of recording a planogram using the "Footscan" device
Analyzing the record, in this case we can not talk about the accuracy of measuring the length of the left foot, it is impossible to calculate the height of the longitudinal arches of the feet, suggest the cause of the asymmetric deformities of the right-left foot, the ratio of the axis of the feet to the shank axes. That is, in the presence of data only plottograms can not be diagnosed and it is impossible to make an individual footbed.
For an objective assessment of the condition of the foot and diagnosis of various diseases, it is necessary to use both generally accepted methods of examination of patients, and methods that take into account the specific features of the foot.
Given the complexity and variety of problems associated with the fact that foot lesions are not only static, but there is a large list of somatic and dermatological diseases that lead to foot damage, which in one article is impossible to list, we propose to analyze the main diagnostic methods thatIt is necessary for a specialist to diagnose and select a method of treatment for the development of static deformations and to ensure the correct choice of orthopedic correctors.
Such methods include: clinical and instrumental:
- is a suboscopic;
- strain gauge;
Clinical: complaints, anamnesis morbi, anamnesis vitae, status localis. The latter includes an external examination of the foot of the skin condition, the determination of the neutral position of the foot and palpation with the study of the volume of motion in the joints, the definition of local points of soreness.
Complaints. At the initial inquiry of the patient it is necessary to specify, on what specifically pains in the foot he complains, their localization, time of occurrence. This will help you to orient yourself in the problem with which the patient has come. But to make a conclusion and make a diagnosis only on complaints is premature. For example: complaints of pain in the calcaneal region on the plantar surface of the foot do not always indicate the presence of the calcaneal spur. On examination and palpation, you can identify both fasciitis and the presence of a wart in this zone, and other causes.
Anamnesis morbi et vitae. Careful collection of the patient's medical history and life is of no small importance. Thus, the presence of diseases such as diabetes, gout, rheumatism should be taken into account both in the diagnosis and in the future when choosing a treatment.
Status localis. Examination of the foot is carried out in a neutral position, which is also called the median. Determination of the neutral position of the foot is carried out in three positions: lying on the back, lying on the stomach and standing, which is necessary for the correct production of plaster casts of the foot, which then make a steletic orthesis.
Examination of the posterior foot is performed as follows: through the middle of the Achilles tendon and the center of the calcaneus, a strictly vertical line( either by a plumb or laser level) - the axis of the posterior foot. A valgus deviation of it to an angle of 6 ° is considered normal. An external deviation greater than 6 ° is pathological( pes valgus);the internal deviation above 0 ° causes the varus deformity of the foot( pes varus).
After this, the shape of the forefoot of the foot and fingers is evaluated, as well as the ratio of the forefoot to the posterior. The deviation of the forefoot in the direction of the thumb causes the appearance of deformation - the reduced foot( pes adductus, metatarsus varus);the deviation towards the little finger is the allotted foot( pes abductus, metatarsus valgus).
The relative length of the fingers of the normal foot in different people is not the same. In accordance with the length of the fingers are distinguished:
Features of the structure of the feet predispose to the development of certain static changes. In the Greek form of the foot, in which the first metatarsal bone is shorter than the 2nd and sometimes the 3rd, the flattening of the transverse arch of the arch( transverse flatfoot) occurs most often, as well as the overload of the metatarsal bone head, especially when using the shoe withhigh heels;at the Egyptian foot - development of a static valgus or flat-footed foot( pes planovalgus).
When examining the foot, attention is paid to the color of the skin and their integrity or the presence of various injuries: diaper rash, scuffs, omozolelosti or puffiness of the foot. Inspection of the feet includes its position in space( Figure 2), the severity of the vaults.
Fig.2. Vicious instigation of the foot of the book. VVKovanov and AA Travina.
Functional examination begins with examination of the foot without load, revealing the volume of active and passive movements in the joints of the fingers. With mobile flat feet, you can see that the inner arch of the foot is stored without load and flattened during the load. The position of the heel bones is studied when examining the feet behind in a relaxed position. In this position, it is possible to note the heel bone anatomy and the shift of the Achilles tendon to the outside( a positive Helbing's symptom)( Fig. 3).
Fig.3. Positive Helbing's symptom on the left.
The back flexion in the ankle joint is investigated, because equinus is a frequent component or etiological factor of flatfoot. The valgus position of the heel during the support on the entire foot changes to the varus when standing on the socks, which proves the correctness of the deformation and its mobile character. When palpation is determined by the mobility of the joints of the fingers, the presence of painful points, the elasticity or rigidity of the arches of the foot.
After clinical investigation and preliminary diagnosis, the doctor determines the need for additional instrumental diagnostic methods and only then determines the appropriateness of assigning various types of staple orthoses and other foot devices.
Additional instrumental methods of foot diagnostics
1. Podoskopiya is a method for qualitative visual diagnostics of the condition of the arches of the foot, its shape, location of the foot axes and its sections to the axis of the shin on a special device, a subsoscope.
Podoscope is a device consisting of a reference transparent area, illumination and a viewing mirror, which makes it possible to obtain a picture of the plantar surface of the patient's feet both with static load and without it( Fig. 4).
Fig.4. Inspection of the patient on a podoscope.
This method allows you to qualitatively assess the plantar surface of the foot: load zones, overloads( more often in the form of corns), the severity of the arches, the orientation of the main axes of the foot and the ratio of the axis of the foot to the axis of the lower limb. In combination with other diagnostic methods, the subscope allows you to obtain additional information on the state of the musculoskeletal system of the patient.
With a scoping inspection, it can be seen that the foot normally has three support points: the back support of the foot is the plantar tubercle of the calcaneus;front-inner support - the head of the first metatarsal bone with its two sesamoid bones;anterior-external - the head of the fifth metatarsal bone. In all other cases, podoscopy helps to identify the different degrees of flattening of the arches of the foot, to determine the zones of overload and the distribution of pressure on the various parts of the foot.
2. Podemetry is a method for quantifying the height of the longitudinal arch of the foot( in numerical terms) and reflecting the elastic oscillations of its arc, depending on the load, as well as the quantitative ratio of the other parameters of the foot.
Podometry is performed by an orthopedic doctor using a stopper in a standing position( Figure 5).
Fig.5. Measure the length of the foot stopper.
Measurements of the height of the arch are carried out sitting and standing, it is more convenient on a podscope by means of crossing lines( Fig. 6).
Fig.6. Measurement of the height of the longitudinal arch of the foot.
It is possible to make a sub-meter without the stopper. For this, the subject is put on a piece of paper so that his feet form a right angle to the shins. The height of the foot is determined by measuring the distance from the upper surface of the scaphoid bone( palpated to the transverse toe anterior to the ankle) to the floor. Each of the stops is drawn on paper with a pencil, keeping it strictly perpendicular to the reference surface. On the contour measure the length( in millimeters) of the length of the foot from the tip of the first finger to the rear edge of the heel.
The difference between the height of the arch without load and in the standing position under load is an important diagnostic value. The change in this height by more than 3-4 mm indicates a weakness of the arch due to insufficiency of the ligamentous and muscular apparatus, instability, and flatfoot in one form or another. As a result of measurements and calculations, a "sub-metric index" proposed by MO Fridland, which characterizes the state of the longitudinal arch, is derived.
The sub-metric index( PI) is calculated from the ratio:
PI = Height of the foot( mm) / Length of the foot( mm) X10
Degrees of flatfoot
As can be seen from Table 1. The PI of the foot normally ranges from 29 to 31. Figures above 31 indicatean excessive increase in the longitudinal arch( excavation), below 29 - the flattening of the arch( flat feet).On the outline of the contour of the foot, it is possible to determine the indices of the width of the foot( in the narrow and wide part of it).Using the protractor along the same outline, the angle of the foot adduction( at the border of its anterior and posterior regions) can be measured, and the angles of flexion and extension of the foot are determined. To do this, the protractor should be applied directly to the side surface of it, and to determine the angles of supination and pronation - to the back surface of the foot.
With transverse flatfoot there is an increase in the sub-metrical width in relation to the length of the foot to 42% or more( the norm is 40%).
3. The plantography is a method of obtaining a graphic "print" of the plantar surface of the foot on paper with the subsequent calculation of the degree of flatfoot.
Imprint is obtained on special devices: - plottographs. The plantograph is a frame, tightened by a rubber membrane. Before each measurement, the lower surface of the membrane is smeared with printing ink. Then a sheet of paper is placed under the membrane, the patient rises to the membrane, and the doctor delineates the perimeter of the foot with a special "spatula".
On the obtained print, some reference points of reference are manually connected and quantitative indicators characterizing the state of the patient's feet are calculated. This method is simple and intuitive, does not require expensive equipment and is indispensable for surveys in "field" conditions( Figure 7).
Fig.7. Plantogram at different degrees of flatfoot.
A similar planogram, but already requiring special equipment, can be obtained on a modern scanner, which allows to obtain a stamp of the plantar surface of the foot without a stamp.
There are a lot of methods for estimating planktograms by definition of flatfoot. For example: the methodology of SF Godunov, OV Kozyrev, IM Chizhin, VA Yaralov - Yaroland, etc. All these methods have their advantages and disadvantages. A quantitative analysis of the study of flatfoot and determination of its degree according to the planogram is quite reliable and obvious, but the decision to configure a volumetric stellite orthesis is possible only in conjunction with other methods of investigation.
Since 2001, Kuznetsov S.V.a digital stereo photoplantography system was created. The results of the study are shown in Fig.8 and 9. The author developed a system of detailed analysis of all parameters of the foot.
Fig.8. Example of recording the study of digital stereo photoplantography
Nevertheless, it is obvious that even a detailed stereo photoplantogram analyzing the condition of the plantar surface of the foot does not carry complete diagnostic information and can not serve as a basis for the designation and manufacture of individual stekl orthoses.
In this regard, the author additionally developed an evaluation of the photographic image of a patient's foot standing on a podscope on all sides for a possible evaluation of the ratio of the axis of the foot to the shin.
Fig.9.An example of recording a screen with a survey using digital stereo photoplantography
Digital stereo-photoplantography complexes allow for objective screening and clinical full-scale orthopedic analysis and monitoring. The technology of the complexes includes algorithms for practically all existing clinical clinical outcomes of official orthopedics( up to 214), in particular: the coefficients of longitudinal and transverse flatfoot, the angle of Fick and Shoparov joint, the shape of the foot, automatic determination of the angles of the rear part of the feet due to mathematical projection from the bottom view".
Despite the high degree of informativeness, this method has not yet found wide application in practical public health services and is applied in highly specialized clinics.
Computer strain gage( or the same plottography, but in digital processing of the resulting image) is a study that allows using a special program and a strain gauge platform or strain gages to transfer digital information to a computer, to obtain digital footprints, to analyze the distribution of the body's gravity over their entire surfaceand to obtain data on the weakness or unevenness of the functioning of the foot muscles.
The method of researching the parameters of the pressure of the feet is simple, informative, takes little time, the patient database is stored on the computer, convenient for processing and remote analysis of the results.
The sub-metric research system allows to determine the relative degree of foot pressure on the plane in different modes:
- diagnostics of the foot condition with incomplete load;
- diagnostics of the state of the feet with full load on both feet;
- distribution of pressure on the feet when the center of gravity of the body is displaced in a standing position;
- load determination separately for each foot;
- determination of the load on the front and rear parts of the foot;
- load distribution when walking on the right and left feet;
- as well as the anterior and posterior parts of the foot.
Diagnosis of the pathology of the musculoskeletal system using a sub-metric system undoubtedly has a number of advantages over traditional methods( the study of footprints on glass, sub-graph, paper, scanning of the feet), since it makes it possible to determine the foot support area,, the average pressure under the foot, and the discrete value of the pressure at the separate support areas of the feet( Figure 9).
Fig.10. An example of recording the results of computer-based standing and standing while walking.
The use of computer strain gauges allows an early diagnosis of foot pathology when the deformation is weakly expressed or is hidden, which can not be detected using traditional methods.
Analysis of the results of computer strain gauges of patients with different degrees of longitudinal-transverse flatfoot allows us to fully assess the functional and static properties of the feet, identify overload zones and defects.
When studying the results of computer strain gages in the operation of stellar orthoses under static and dynamic loads, it confirms the possibility of using it for selecting ready-made stitched orthoses, making individual ones and tracing the dynamics of foot pathology in time. Potential possibilities of three-dimensional modeling of orthoses give the orthopedist a new reliable tool for the creative realization of scientific and practical ideas.
The computer base of the patients studied allows to conduct the study in dynamics, perform a comparative analysis and study the results of the ongoing treatment in combination with an assessment of the appropriateness of the chosen orthopedic device.
Interpretation of the results obtained during the examination of patients allows to expand the understanding of the dynamics of the pathology studied, to objectify the choice of a specific orthopedic insoles from several, to justify the selection of additional corrective orthopedic devices, and to improve the methods of complex treatment.
Diagnostics is clear, the image on the foot monitor under load allows to explain to the patient the nature of his pathology, to adjust it for the performance of the curative program. Step-by-step studies of patients using the system allow you to correct the treatment and the type of orthopedic care.
4. The radiological method of examining the foot is informative and reliable. But it is necessary to comply with the basic rules of the study: the correctness of the installation of the foot at the time of examination, the sharpness and contrast of the radiograph( Fig. 10).
Fig.11. Side projection of the foot on the roentgenogram, where the angle "α" and the height "H" are distinguished.
To calculate the longitudinal arch of the foot on the roentgenogram, three lines are drawn in the lateral projection:
1st line - horizontal, tangential to the plantar surface of calcaneal tuber and head1st metatarsal bone;
The 2nd line is drawn from the point of contact of the 1st line with the calcaneal tubercle to the lowest point of the navicular-wedge-shaped articulation;
The 3rd line is drawn from the point of contact of the 1st line with the head 1 of the metatarsal bone to the lowest point of the navicular-wedge articulation.
The "α" angle of the arch of the foot is formed by the 2nd and 3rd lines, which intersect at the lowest point of the navicular-wedge joint.
The height "H" of the longitudinal arch of the foot is the length of the perpendicular dropped from the lower point of the navicular-wedge joint( the points of intersection of the 2nd and 3rd lines) to the 1st( horizontal) line.
Normally, the angle of the longitudinal arch of the foot is 125-130 °, the height of the arch is> 35 mm.
The technical equipment and variety of instrumental methods for studying various parameters of the foot should not push the general plan of the clinical examination of the patient. So, it is impossible to correctly diagnose and prescribe an adequate treatment on the basis of just one study.
For a correct choice of tactics of orthotics, a thorough clinical assessment of the condition and function of the foot is necessary, using the data of additional research methods: X-ray, sub-metric, planographic and subgraphic methods.
Based on this, it can be concluded that it is impossible to make a stele orthosis on the basis of just one method of research, since the goal of orthosis is not fully achieved - the foot is placed in a neutral position, the foot functions are improved by uniform redistribution of static and dynamic loadson the foot, restoring the spring function of the foot, compensating for the difference in the length of the lower limbs, eliminating the zones of local overloads.
There are several ways of foot orthosis:
- if possible, the choice of a standard stellite orthosis, - orthosis using standard factory blanks, - individual orthoses for plaster casts.
Application of standard semi-finished products and finished products is possible in those cases when the individual parameters of the orthotized foot correspond to the average statistical parameters of models used in the fabrication of orthoses. The presence of pronounced deformities of the foot is an indication for the use of an industrially manufactured orthosis. At present, there are several methods of individual manufacturing of foot orthoses. Work on the comparative evaluation of different methods, to date, no. In the individual manufacture of orthoses, both loading and non-loading methods for obtaining a negative impression of the foot are used to make a gypsum model, after which the correcting elements of the orthoses are formed.
The immediate effect of the use of foot orthoses is to reduce pain and improve walking parameters. In addition, it has been shown that the use of insoles reduces the use of non-steroidal anti-inflammatory drugs in patients with gonarthrosis.
The main factor influencing the efficiency of the orthoses of the foot is their correct selection in strict accordance with the individual parameters of the foot of the patient and the peculiarities of the functional disorders that occur. It is shown that the use of insoles with an elevated lateral margin in combination with an elastic ankle articulation leads to a significant reduction in pain in the knee joints in patients with medial gonarthrosis.
If the orthosis is incorrectly selected and its relief does not correspond to the relief of the foot, complications can arise in the form of strengthening of painful sensations during walking, the appearance of scuffs and skin numbness of the skin. In this case, the use of orthosis should be stopped immediately and seek the help of a specialist.
Undoubtedly, the doctor should take into account his informativeness and expediency when assigning a survey. So, for example, planographic and tensometric methods carry similar information, but at a different technical level. Therefore, for more complex surveys, it is advisable to combine opto-mechanical methods with surveys using modern electronic-mechanical systems. But the sub-scopic and sub-metric methods complement each other.
Thus, the examination of each patient and the selection or decision-making on the manufacture of an individual insole requires a meaningful clinical approach using additional instrumental research methods.
Traumatic platypodia develops as a result of injured bones of the feet( fractures, dislocations, etc.) or surgical intervention
Paralytic platypodia occurs in people with paralysis of some muscle groups of the lower extremities that have arisen as a complication of poliomyelitis
Ricket platypoda , as the name suggests, is provoked by rickets. Rickets is a serious disease of the bone system associated with a deficiency of calcium and vitamin D. The bones lose their elasticity and easily deform, like clay.
Static flatfoot is the most common form of the disease. This is an acquired disease and it is caused by an incorrect way of life. Excess weight, non-physiological footwear, professions with increased strain on the feet - these are the sources of static flatfoot. As research shows, about 80% of cases of flat feet - this is the static version of the disease.
Valgus flatfoot is more common in children. With this pathology, not only the arches of the foot decrease, but the axis of its normal position also changes. The foot is turned inward, when walking the whole surface of the sole is pressed against the floor.
Flattening: Degree of disease
Depending on the level of deformation and severity of consequences, three degrees of flatfoot are distinguished.
- The first degree almost does not bother the patient, since it has no painful manifestations. This is rather a cosmetic defect - the leg slightly loses the grace of form.
- The second degree is called intermittent flatfoot and already makes itself felt periodically arising unpleasant sensations - pain, increased fatigue, changes in gait, calluses and corns.
- The third degree is characterized by complete deformation of the foot and causes serious troubles - pains spread to large joints( knee, hip) and spine, arthroses and intervertebral hernias occur, walking is severely hampered, sports activities are impossible.
The characteristics of the degrees of flatfoot differ depending on its type.
Degrees of longitudinal flatfoot are determined by measuring the angle of the arch of the foot and its height.
I degree - the angle of the arch 130 - 140о, height 35 - 25 mm;
II degree - angle 140 - 155o, height 25 - 16 mm;
III degree - angle greater than 155o, height less than 16mm
The degrees of transverse flatfoot are determined by the angle between the first and second metatarsal bones.
I degree - up to 12o
III degree - 15 - 20 and more.
Flat-footedness: symptoms, diagnosis, consequences
Flat-footedness is far from harmless. Therefore, a timely diagnosis of flatfoot is very important. Our foot is the foundation for the entire skeleton, and its incorrect position entails displacement in the joints of the legs and, as a consequence, a disruption of the normal setting of the spine. And since the spine is responsible for the work of all organs and systems without exception, the health of the whole organism is under threat. This is not counting pains, seizures and increased fatigue of the lower extremities, degenerative changes in the knee, hip and ankle joints, varicose veins, the appearance of painful bone and callous growths. If you do not struggle with this condition, the quality of life will greatly drop.What are the symptoms that should trigger an alarm?
Periodically appearing pain in the feet, visible deformation of the feet, a decrease in their arches and curvature of the axis, clubfoot, changes in gait. Particular attention is required for children's flat feet, because children's bones have not lost their plasticity and, having started treatment in time, it is possible to improve the situation. Launched the same "adult" platypodia is almost impossible to cure, here all measures will be aimed at compensating for the harm caused by the flatfoot.
Diagnosis of flatfoot is carried out using a set of methods.
- Plantography .An ingenious and extremely simple method, available at home. The feet are greased with a thick cream, after which the patient is asked to stand barefoot on a clean white sheet of paper. It is necessary to stand straight, in a natural position. After two three minutes, the traces on the paper are clearly imprinted, the picture of which will tell you eloquently whether you have a flat foot or not.
- Radiography .The usual and usual X-ray.
- Subdomain. Calculations based on the measurement of the angles of the arch of the foot and its height.
In addition, the doctor will listen carefully to all complaints of the patient and will collect a detailed anamnesis.
Methods of treating flatfoot
As we already noted above, it is impossible to completely heal the pronounced flat feet( second and third degree) in an adult due to the stiffness of the bone skeleton. But it is possible to compensate for the pathological conditions caused by flatfoot, and also to slow down its further development. Let's talk about what flatfoot therapies exist and can help us.
You need to start with shoes. Sadly, if you are diagnosed flat feet, you will have to abandon the model narrow shoes with high heels. It is best to use a special orthopedic footwear, which provides the most natural position of the feet when walking. If there is no possibility to constantly wear such "medical" shoes, be sure to order orthopedic frame insoles - arch supports. They invest in casual shoes. The rigid frame of such insoles forcibly forms absent arches of the foot, removing the basic symptoms of flatfoot. You need to wear insteps constantly.
If you have extra pounds, it is better to get rid of them. And for healthy bones, healthy nutrition will be beneficial. Do not forget to eat foods that contain calcium and promote its absorption( fermented milk products, cottage cheese, fish, nuts, vegetables, etc.).It is advisable to use vitamin complexes with vitamin D.Massage is another integral component of the treatment of flatfoot. Massage can be of two kinds - manual and natural. A natural massage consists of walking barefoot on a relief surface. It can be a rug with protrusions or a surface that is densely paved with pebbles. Walking on the ground or on sand is also welcomed, if not threatened with all sorts of cuts, splints and other injuries.
special gymnastics plays an important role in the treatment and prophylaxis of flatfoot. Exercises with flat feet should help strengthen the muscles of the foot, the elasticity of the ligaments and the flexibility of the joints.
The peculiarity of combating flatfoot is that it must be done regularly and constantly, throughout life, otherwise the disease will inevitably progress.