This document provides information about various foot conditions including pes cavus, pes planus, and their treatment. It defines pes cavus as a foot with an abnormally high arch. Pes planus is defined as flat foot where the arch is lost. Flexible flat foot has an arch when not weight bearing but it disappears with weight bearing. Rigid flat foot lacks an arch with or without weight bearing. Conservative treatments for flexible pes planus include orthotics and exercises while rigid pes planus may require surgery if causing symptoms. Surgical options are also discussed for treatment of pes cavus and rigid pes planus.

2. Sreeraj S R
• Club foot
https://www.slideshare.net/sreerajsr/physiotherapy-
for-congenital-talipes-equinovarus
• Pes cavus
• pes planus
• Metatarsus adductus
• Splay foot

3. Sreeraj S R
• Pes cavus is a foot with an abnormally high plantar
longitudinal arch.
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https://www.physio-pedia.com/Pes_cavus

4. Sreeraj S R
a. b. c.
a. Typical appearance of ‘idiopathic’ pes cavus. Note the high arch and claw-
toes.
b. This is associated with varus heels.
c. Look for callosities under the metatarsal heads.
Apley’s System of Orthopaedics and Fractures, 2010

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• The etiology can be attributed to the brain, spinal
cord, peripheral nerves, or structural problems of the
foot.
• Some of the factors considered influential are:
• Muscle weakness and imbalance in neuromuscular disease such
as spinal cord abnormalities and poliomyelitis
• Residual effects of congenital clubfoot
• Post-traumatic bone malformation
• Contracture of the plantar fascia
• Shortening of the Achilles tendon
• Overpull of the flexor digitorum longus

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• Clawing of the toes
• Increased calcaneal angle
• Contracture of the plantar fascia
• Cock-up deformity of the great toe.
• There is increased weight bearing on
the metatarsal heads leading to
Metatarsalgia and calluses.

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a) The calcaneum, 1st and 5th metatarsals are likened to the spokes of a tripod.
b) When the 1st and 5th rays are drawn closer to the heel, a plantaris deformity is
present.
c) The 1st ray alone is drawn towards the heel, which itself is in varus.
d) In calcaneus, the heel is pushed plantarwards.
e) In calcaneo-cavus deformity the heel is in calcaneus and the 1st ray is drawn in.
Apley’s System of Orthopaedics and Fractures, 2010

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• The Coleman block test is
useful to check if the
deformity is reversible.
• With the patient standing
on a low block to permit the
depressed first metatarsal
to hang free, the heel varus
is automatically corrected if
the subtalar joint is mobile.
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10. Sreeraj S R
• Flexible pes vavus which are symptom free can be
left untreated with some shoe corrections as they
have difficulty of fitting shoes.
• Progressive deformities needs more attention.
• Insoles provide comfort but does not alter the
deformity or influence its progression.

11. Sreeraj S R
• Orthotics with extra-depth shoes to offload bony
prominences and prevent rubbing injuries.
• For varus deformities, a lateral wedge sole
modification can improve function.
• Bracing with foam linings may allow patients to
ambulate
• In patients with sensation deficits frequent
inspection of the skin for ulceration is warranted.

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• Cavus Foot Exercises
• Towel Stretch: Sitting with feet in front, loop a towel around the ball of the foot. Gently
pull the towel in foot dorsiflexion direction to stretch structures of plantar aspect, toes
and calf muscles.
• Bent-Knee Wall Stretch: Stand roughly a foot from a wall with palms flat against it.
Keeping heels flat on the ground, bend both knees and lean whole body forward slightly,
using the wall to balance.
• Toe Squeeze: Squeeze toes together as hard as one can for ten seconds, then relax and
repeat.
• Toe Rolls: With feet flat on the ground, raise just the toes up. Slowly lower the toes one
at a time so they “roll” back down to the ground.
• Golf Ball Pick-Up: Using toes, try to pick up a golf ball from the ground and put it into a
bucket. If this to too hard to start, use a washcloth and marbles first.
• Towel Toe Curls: Pull the towel laid on the floor towards and away using all the toes.

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• An equinus contracture is dealt with by lengthening of the Tendo Achilles and posterior
capsulotomies of the ankle and subtalar joints.
• Jones procedure is performed for a cockup deformity or clawing of the great toe with
associated weakness of the anterior tibialis.
• Extensor shift procedure transferring the EHL and the EDL to the first, third, and fifth
metatarsals.
• The Girdlestone-Taylor transfer procedure is used for flexible claw toe deformities. Flexor
digitorum longus (FDL) tendon is transferred to the extensors to correct the deformity.
• Dorsiflexion osteotomy at base of first metatarsal in patients with a fixed plantarflexed first
ray, combined with a plantar fascia release or a Jones procedure
• Midfoot/ Tarsal osteotomy has been described for deformities through the midfoot
• Peroneus longus to peroneus brevis tenodesis in patients with a weak PB and a preserved
PL, to help stabilize the ankle. This is frequently combined with a calcaneal osteotomy.
• Calcaneal osteotomy in patients with hindfoot involvement

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• Cavus foot reconstruction involves bone, tendon,
and/or ligament reconstruction to stabilize the ankle
and hindfoot.
• A calcaneus and first metatarsal osteotomy, the
peroneal tendons, Achilles tendon, the plantar fascia
release and lateral ankle ligaments are often
addressed.

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• WEEKS 1 - 5:
• STRICT non weightbearing in splint x 6 weeks
• Elevate the leg above the heart to minimize swelling 23
hours/day
• Ice around the area or proximal.
• Focus on rest
• Hip and knee AROM, hip strengthening
• Core and upper extremity strengthening
• Chest PT

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• WEEKS 6 - 12
• Active/passive ankle ROM to non-fused joints:
o Subtalar arthrodesis: mid and forefoot only
o Triple arthrodesis: DF and PF only
• Isometric in all planes allowed, and early isotonic ankle planes
mentioned above according to procedure
• Foot intrinsic strengthening
• Scar massage
• Joint mobs to NON-fused joints as needed for ROM gains
• Stationary bike IN boot start at 6 weeks

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• WEEKS 6 – 12
• Partial weight bearing progress to FWB in boot based on x-
rays showing adequate healing and surgeon instruction.
• Progressive weight bearing in boot, using crutches/walker,
starting with 25% weight and increasing by 25% every 1-2
weeks until fully WB in boot
• When the patient can hit 75% of body weight without
aggravation of symptoms, begin to use one crutch in the
OPPOSITE arm

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• WEEKS 12 - 14:
• Transition to a regular shoe, once able to fully weight bear in
boot
• start using a shoe inside the house and advance to outside
activities gradually
• Use ankle stabilizing orthosis when outside or on uneven
surfaces
• Low level balance exercise
• Gait training
• Continue PT with progressive hip, knee, and ankle strengthening
• Stationary bike, swimming activities are okay

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• WEEKS 14 – 16:
• May resume running, impact activities
• Normalize gait mechanics
• Full functional ROM of all free joints
• Single leg balance and proprioceptive exercises to advance as
able
• Bilateral, progress to unilateral heel raises
• Goal of full strength at 16 weeks
• Gradual progression to non-impact cardio-vascular and fitness
activities

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• Precautions
• DO NOT attempt to gain motion in the planes that were
fused
• For subtalar/triple arthrodesis, focus only on
dorsiflexion/plantarflexion (DO NOT ATTEMPT side to side
motion)

21. 21

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• Pes planus also known as
flat foot is the loss of the
medial longitudinal arch of
the foot,
• Heel valgus deformity, and
medial talar prominence.
• All at birth has flat feet and
noticeable foot arch are
seen at around the age of 3
years.
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https://in.pinterest.com/pin/440156563566321417/

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• It is of two forms;
1. Flexible flat foot: If the arch of the foot is intact on
heel elevation and non-weightbearing but
disappears on weightbearing, it is termed flexible flat
foot
2. Rigid flat foot: Rigid flat foot is when the arch is not
present in both heel elevation and weight bearing.

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• Deformities such as;
• CTEV
• Ligamentous laxity,
• Foot equinus deformity,
• Tibial torsional deformity,
• Presence of the accessory navicular bone,
• Congenital vertical talus
• Tarsal coalition.
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25. Sreeraj S R
• Diabetes and obesity
• Injury such as rupture or dysfunction of the posterior tibial
tendon
• Genetic malformation such as Down syndrome and Marfan
syndrome
• Familial factors
• Arches weakness due to overuse or injuries
• Some medical conditions such as arthritis, spina
bifida, cerebral palsy, Arthrogryposis, and muscular dystrophy.
• During pregnancy.
• Iatrogenic factors such as posterior tibialis tendon (PTT)
transfer.
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a) Standing with the feet flat on the floor, the medial arches appear to have dropped
and the heels are in valgus.
b) When the patient goes up on his toes, the medial arches are restored, indicating
that these are ‘mobile’ flat feet.
a) b)

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• The arch can often be restored by simply dorsiflexing
the great toe,
• during this maneuver the tibia rotates externally.
• The subject may have ligamentous laxity.
• There may be a family history B/L flat feet and joint
hypermobility.

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• A flexible flatfoot produced by means of the “windlass action” of the plantar fascia.
• The plantar fascia originates on the plantar aspect of the calcaneus and inserts into the
plantar aspect of the toes.
• Great toe dorsiflexion pulls the plantar fascia distally under the pulley of the head of
the 1st MT.
• Since the plantar fascia is of fixed length, the great toe can only fully dorsiflex if the
calcaneus is pulled distally toward the MT heads, thereby elevating the longitudinal
arch, and inverting the subtalar joint.

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• The plantar arch index establishes a
relationship between the central and posterior regions
of the footprint, and it is calculated as follows:
1. A line is drawn from the medial forefoot edge to
the mid-heel region.
2. From the midpoint of this line, a perpendicular is
drawn, as mid-foot width (A).
3. From the mid-heel point another perpendicular
line was drawn as mid-heel width (B).
4. The plantar arch index is calculated as PAI = A/B.
Vangara SV, Int J Anat Res 2019
https://www.e-arm.org/journal/view.php?number=778

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• SAI score
1. 0.3 - 0.7 normal,
2. > 0.7 flat foot/PP
3. < 0.5 as high arch
foot/PC
30

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• Foot pain due to strained muscles and soft tissues;
• Most of the weight bearing on the foot deviated medially.
• Some individuals have an inward turned ankles
• The detorted weight bearing could result in abnormal lower
limbs biomechanics.
• Possible oedema at the medial side of the foot
• Stiffness of one or both arches of the feet.
• Uneven distribution of body weight with resultant one-sided
wear of shoes leading to further injuries.
• Difficulty in walking

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1. Physiological flexible flat-foot in young children require no
treatment.
• Parents need to be reassured and told that the ‘deformity’ will
probably correct itself in time and function is unlikely to be impaired.
• Use of insoles or molded heel-cups alter the pattern of weightbearing
and hence that of shoe wear
2. Flat-foot associated with a tight tendo Achillis and
restricted dorsiflexion may benefit from tendon-stretching
exercises.

33. Sreeraj S R
3. Kidner’s operation can be tried for an extra bone in their
foot, known as an accessory navicular bone.
• The procedure involves detaching the bone from the
posterior tibial tendon and then removing it entirely from
the foot.
• The tibial tendon is then reattached, and the incision is
closed with stitches.
• Patients will likely need to use crutches after surgery and
should be able to resume all physical activity after six
weeks.

34. Sreeraj S R
4. Rigid flat-foot due to tarsal coalition require treatment if they are
causing symptoms.
• Nonsurgical Treatment
1. Rest. Taking a break from high-impact activity for a period time —
3 to 6 weeks — can reduce stress on the tarsal bones and relieve
pain.
2. Orthotics. Arch supports, shoe inserts like heel cups and wedges
to help stabilize the foot and relieve pain.
3. Temporary boot or cast to immobilize the foot and take stress off
the tarsal bones.

35. Sreeraj S R
4. Rigid flat-foot due to tarsal coalition require
treatment if they are causing severe symptoms.
• Surgical Treatment is for sever cases.
1. Resection. the coalition is removed and replaced with
muscle or fatty tissue from another area of the body. It
preserves normal foot motion
2. Fusion. Larger, more severe coalitions may be treated with
joint fusion to limit movement of painful joints and place
the bones in the proper position.

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• Functional foot orthoses (FFOs) have a role to play in
the adult flexible but symptomatic flat-foot.
• These orthotics are used to correct abnormal
function or biomechanics of foot and lower
extremity
• Orthoses may be made of flexible, semi-rigid or rigid
plastic or graphite materials which are relatively thin
and fit easily into several types of shoe.

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• If conservative treatment fails, then surgical intervention
should be considered.
• Options include;
1. Surgical decompression and tenosynovestomy, Gastrocnemius
Recession, tibialis posterior reconstruction with or without a calcaneal
osteotomy to help to protect the tendon and improve the axis.
2. Triple arthrodesis i.e., fusing the subtalar, calcaneo-cuboid and
talonavicular joints.
3. Medial displacement calcaneal osteotomy with FDL or FHL transfer.
4. Cobb procedure: The Tib. Ant. tendon is split, passed through the Tib.
Post. insertion sheath and attach to its stump proximally to restore the
arch.

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1. Delayed wound closure
2. Bleeding
3. Infection
4. Swelling
5. Stiffness in the forefoot,
midfoot and transverse
tarsal joints
6. Nonunion
7. Hardware failure
8. Nerve damage
9. Deep vein thrombosis
10. Pulmonary embolism
11. Persistent pain
12. Recurrent flat foot
deformity
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• 0-6 weeks:
• Cobb Procedure:
• NWB in POP in plantar-flexion / inversion for 8 weeks
• FWB at 8 weeks in POP
• FDL/FHL Transfer:
• NWB in POP for 6 weeks.
• FWB in aircast/ Controlled Ankle Motion (CAM) boot at 6 weeks.
• Ankle specific Physiotherapy at 6 weeks
• Should return to work from 4 weeks postoperatively
• No strengthening against resistance to ankle until at least 3 months post-
operatively
• Do not stretch. It will naturally lengthen over a 6-month period

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• Patient should be out of POP at;
1. 8 weeks post-operatively in Cobb Procedure
2. 6 weeks postoperatively at FDL/FHL transfer

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• Weeks 0 – 6/8
1. Strict Limb elevation every hour
2. Oedema Control
3. Pain control
4. Inflammation control
5. Deep breathing & chest PT
6. Frequent bed mobility to prevent skin breakdown
7. SLR in all directions

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• Weeks 0 – 6/8
1. Lower extremity stretches (hamstring, hip flexors, quads,
glutes, hip rotators)
2. Pelvic and core stabilizing exercises
3. Hip and knee strengthening, static to dynamic
4. Toe PROM/AROM
5. 4-way ankle isometrics in cast
6. Patient is encouraged for bedside sitting for dynamic exercises
with/without resistance to other areas.
7. Gait training in NWB with appropriate assistive device

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• Weeks 6/8 -12
• Progressive weight shifting onto affected extremity
• Gait training in cast or Controlled Ankle Motion
(CAM) boot
• Progress to supportive shoe
• AROM to ankle and hindfoot all planes 3 times/day for 10
minutes, holding end range for 10 seconds
• Forefoot towel scrunches
• Gentle Gastrocnemius, Soleus stretching

44. Sreeraj S R
• Weeks 6/8 - 12
1. Closed chain exercises
2. Double limb proprioceptive exercises: on foam, biomechanical
ankle platform system (BAPS) board, rocker board, partial
tandem/tandem stance
3. Strengthen medial ankle and arch with foot doming exercises
4. Scar mobilization
5. Stationary bike in boot/shoe
6. Core, upper and lower extremity strengthening
7. Provision and Education on appropriate footwear and/or
orthotic use to prevent hyper pronation

45. Sreeraj S R
• Weeks 12 - 24
• Single limb stance activities
• AAROM and PROM to ankle and foot
• Resisted exercises using theraband
• Manual Therapy to increase ROM, decrease soft tissue restrictions
• Double limb heel raises
• Eccentric Gastrocnemius strengthening
• Single limb heel raises
• Biking with resistance
• Rowing
• Treadmill walking
• Plyometrics and agility drills if appropriate

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• It is one of the commonest of the foot
deformities.
• The elements of the deformity are;
• Lateral deviation and rotation of the hallux
• Prominence of the medial side of the head of the first
metatarsal (a bunion).
• Can lead to overcrowding or overriding of adjacent
toes.
• The great toe rotates into pronation so that the nail
faces medially

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• There is development of soft tissue and bony
prominence/Exostosis on the medial side called a bunion
• It is a progressive foot deformity accompanied by
• Significant foot pain,
• Reduced quality of life
• Functional disability
• Impaired gait (lateral and posterior weight shift, late heel rise,
decreased single-limb balance, pronation deformity)

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• Incidence is 10 times more in women
• Congenital deformity or predisposition
• Severe flatfoot
• Hypermobility of the first metatarso cunieform joint
• Abnormal muscle insertions can be responsible for hallux valgus
• Wearing tight pointed shoes
• Wearing high-heeled shoes
• May be congenital
• May result from loss of muscle tone in the forefoot in elderly people.
• Common in rheumatoid arthritis, probably due to weakness of the joint capsule
and ligaments.
• Heredity; a positive family history is obtained in over 60 per cent of cases.

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• The great toe is in valgus
• There is bunion over the medial side of the first metatarsal head varies in
appearance from a slight prominence to a red and angry looking bulge
that is tender.
• Pain over the bunion, forefoot.
• The period of single-limb support will be diminished in gait.
• Unable to supinate foot
• Body weight is on the lateral border of the foot resulting in a late heel rise
• The MTP joint may or may not be osteoarthritic. This depends on duration
of the case
• There may be planovalgus hindfoot collapse with the patient standing.

50. Sreeraj S R
• Pain & Tenderness of hallux
• Lateral deviation of the MTP joint
• Swelling of first MTP joint
• Weakness of abductor hallucis muscles
• Shortening of adductor hallucis and flexor hallucis
brevis muscle

51. Sreeraj S R
A. No deformity (grade 1)
B. Mild deformity (grade
2)
C. Moderate deformity
(grade 3)
D. Severe deformity
(grade 4).
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• Hallux Valgus Angle
• It is the angle between
the axis of the 1st
metatarsal and the axis of
the proximal phalanx of
the 1st toe.
• A normal angle is ≤ 150.
• A greater value
indicates hallux valgus.
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Parekh SG (2012)

53. Sreeraj S R
• Comorbidities of hallux valgus might be included in the
management;
• Bunion
• Osteoarthritis of the big toe
• Hallux rigidus.
• Bursitis on the toe pads and at adjacent lesser toes.
• Painful overload on the lesser toes
• Claw toes
• Hammertoes

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• If the condition is mild and not interfering with activity, then it can be left
alone, and the patient reassured.
• Pain can be relieved by NSAIDs, injection of corticosteroid and local
anaesthetic.
• Physiotherapy include;
• Cryotherapy if there is active inflammation OR Heat with PWB, Moist heat
packs etc. for non-acute cases for pain and discomfort.
• Soft-tissue manipulation with traction and mobilizations of the big toe
joint and other joints of the ankle or foot for pain as well as stretch for the
tissues around the joint.
• Gait training if not causing pain to effected foot.
• In severe cases, provide physiotherapy as Pre-op.

55. Sreeraj S R
• Adjustment of footwear to help in eliminating friction at the
level of the medial eminence (bunion)
• This consists shoes with wide and deep toe boxes, soft uppers
and low heels
• ‘Trainers’ are a good choice.
• Bunion pads (like a doughnut
shape) to offload the tender
bunion.
• Bunion night splints.

56. Sreeraj S R
• Exercises for bunion relief and prevention
• Toe points and curls
• Toe spread-outs
• Toe circles
• Resisted Toe abduction exercises
• Ball roll
• Towel grip and pull
• Marble pickup
• Figure eight rotation
• Barefoot beach / loose sand walking
• Heel raise

57. Sreeraj S R
• Most hallux valgus surgeries consist of several of the following procedures:
1. Repositioning the bone (osteotomy):
This straightens the foot ray.
2. Soft tissue correction (lateral release):
A rigid misalignment can be straightened by correcting the joint capsule.
3. Tendon correction:
The length of the tendon must be corrected so the pull of the tendon
does not deform the big toes again.
4. Treating the metatarsophalangeal joint:
Joint-preserving cheilectomy (removing bone spurs) or fusing the
metatarsophalangeal joint (arthrodesis) for severe arthritis.

58. Sreeraj S R
• Patient education on how to monitor sensation,
colour, circulation, temperature, swelling.
• General and gait assessment
• Instruct and demonstrate safe ambulation with
assistive devices, NWB with transfers and stairs
• Improve general muscle strength to cop with post op.
life.

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• 0-2 weeks
• Goals
• Manage swelling and pain
• Prevent infection
• Demonstrate safe ambulation with assistive device NWB
• Able to maintain NWB with transfers and stairs
• Perform ADLs in a modified independent manner or with
minimal assistance
Osteotomy &/ Fusion:
Always wear post-operative splint
Non-weight-bearing (NWB)
No joint mobilization of fused joints

60. Sreeraj S R
• 0-2 weeks
• Edema management
• Rest and elevation of the involved lower extremity above the heart
throughout the day
• Ice for 10 minutes every hour, on top of bandage
• ATM/Heel slides/ AROM of hip and knee/ Straight leg raises
• Gait training with precautions on NWB on day – 0
• Full weight bearing in post operative sandal can be considered if it is only
Bunion Correction from day - 1
• No joint mobilization of fused joints
• A Short leg cast will be always on in case of joint fusion
• May be touch down weight bearing only in case of joint fusion.
• Education/modifications for ADLs

61. Sreeraj S R
• 2-6 weeks
• Goals
• Manage swelling
• Protect the osteotomy/fusion site
• Increase range of motion at the 1st MTP and ankle
• Minimize the loss of strength in the core, hips, and knees
• Confirm safety with assistive device NWB/heel touch weight bearing
• Independence with home exercise program to be performed daily
• Increase scar mobility
Osteotomy &/ Fusion:
• Always boot on except for exercise
• Sleep in boot
• May progress to PWB with boot

62. Sreeraj S R
• 2-6 weeks
• Continue 0-2 weeks protocol plus;
• Incision/scar inspection and Scar mobilization once incisions are
fully healed.
• PROM/ AAROM
• Strengthening for core, hips, knees
• Gait training to ensure safety and to proper technique with heel
touch weight bearing
• For Bunion Correction only cases, Post operative sandal
removed and normal shoe worn.

63. Sreeraj S R
• 6-10 weeks
• Goals
• Full ROM of the foot and ankle
• Increase strength of the foot and ankle and maintain hip
and knee ROM/strength
• A normalized gait pattern on all surfaces in boot
• Restore cardiovascular endurance

64. Sreeraj S R
• 6-10 weeks
• Ankle and MTP active/passive range of motion, stretching
• Strengthening exercises for the foot and ankle
• Joint mobilization techniques by the PT to restore motion of the foot
and ankle with proper stabilization - avoid movement at
osteotomy/fusion sites.
• Continue with strengthening for core, hips, knees
• Gait training to wean off the assistive devices and normalize gait in
boot
• Begin stationary bike avoiding pressure on forefoot (not until 10 weeks
in fusion cases)
• Balance and coordination exercises with boot on

65. Sreeraj S R
• 10-14 weeks
• Continue with treatment for strength, range of motion and
conditioning as above with progression
• Assist patient with casual shoe/dress shoe selection
• Start weaning out of boot to supportive sneaker with adequate
width/length toe box
• Single leg activities on varying surfaces with shoes on
• Begin proprioceptive, balance, and motor control exercises in
closed chain
• Stationary bike, swimming, Pool walking

66. Sreeraj S R
• Also, Hallux Limitus is a degenerative
condition leading to reduced rang of
motion in the first MTP joint of the
great toe impairing normal propulsive
phase during gait function.
• Hallux Rigidus is a progressive
disorder where the great toe’s motion
is decreased over time.
Gavin B, 2010

67. Sreeraj S R
• It may be due to;
• Local trauma or osteochrondritis dissecans of the first
metatarsal head.
• Longstanding joint disorders such as gout, pseudogout or
osteoarthritis
• Often bilateral.
• Men and women are affected with equal frequency.
• A family history is common.

68. Sreeraj S R
• Pain on walking.
• altered gait by transferring weight across to the lesser toes
• The outer side of the sole of the shoe may be unduly worn
due to this
• Adjusted toe-off during the gait cycle.
• The great toe is straight and often has a callosity under the
medial side of the distal phalanx.
• A tender dorsal ‘bunion’ at MTP joint.
• MTP Dorsiflexion is restricted and painful, and there may be
compensatory hyperextension at the interphalangeal joint.
• X-rays may show narrowing of the joint space, subchondral
sclerosis and marginal osteophytes.
https://orthopaedia.com/page/Disorders-of-the-Great-Toe
Dorsal bunion

69. Sreeraj S R
• Hattrup and Johnson radiographic classification:
• Grade 1: mild to moderate osteophytes with good
joint space preservation
• Grade 2: moderate osteophyte formation with joint
space narrowing and subchondral sclerosis
• Grade 3: marked osteophyte formation and loss of
the visible joint space, with or without subchondral
cyst formation

70. Sreeraj S R
1. Grade 0:
• Dorsiflexion 40-60°
• Normal radiography
• No pain
2. Grade 1
• Dorsiflexion 30-40°
• Dorsal osteophytes
• Minimal/ no other joint changes
3. Grade 2
• Dorsiflexion 10-30°
• Mild to moderate joint narrowing
or sclerosis
• Osteophytes
4. Grade 3
• Dorsiflexion less than 10°
• Severe radiographic changes
• Constant moderate to severe pain
at extremities
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Coughlin and Shurnass classification:
5. Grade 4
• Stiff joint
• Severe changes with loose bodies and
• osteochondritis dissecans

71. Sreeraj S R
1. Grade 0:
• Dorsiflexion 40-60°
• Normal radiography
• No pain
2. Grade 1
• Dorsiflexion 30-40°
• Dorsal osteophytes
• Minimal/ no other joint changes
4. Grade 3
• Dorsiflexion less than 10°
• Severe radiographic changes
• Constant moderate to severe pain
at extremities
5. Grade 4
• Stiff joint
• Severe changes with loose bodies
and
• osteochondritis dissecans
71
Coughlin and Shurnass classification:
3. Grade 2
• Dorsiflexion 10-30°
• Mild to moderate joint narrowing or
sclerosis
• Osteophytes

72. Sreeraj S R
• If the condition is mild and not interfering with activity, then it can be left alone,
and the patient reassured.
• Pain can be relieved by NSAIDs, injection of corticosteroid and local anaesthetic.
• Physiotherapy include;
• Cryotherapy if there is active inflammation OR Heat with PWB, Moist heat packs
etc. for non-acute cases for pain and discomfort.
• Soft-tissue manipulation with traction and mobilizations of the big toe joint and
other joints of the ankle or foot for pain as well as stretch for the tissues around
the joint.
• Gait training if not causing pain to effected foot.
• Firm-soled sneakers, boots and sandals OR Rocker bottom shoes may be beneficial
• In severe cases, provide physiotherapy as Pre-op.

73. Sreeraj S R
• Cheilectomy: For the early phase, shaving off the
bone spur over the metatarsal.
• Osteotomy: If the movement of MTP joint is stiff,
then an osteotomy of the phalanx with/without
cheilectomy is required.

74. Sreeraj S R
• 0-2 weeks:
• Goals
• Manage swelling and pain
• Prevent infection
• Demonstrate safe ambulation with assistive device FWB
• Able to maintain FWB with transfers and stairs
• Perform ADLs in a modified independent manner or with
minimal assistance
Osteotomy &/ Fusion:
No joint mobilization of fused joints

75. Sreeraj S R
• 0-2 weeks:
• Foot is protected in dressings.
• Expect numbness in the foot for 12-24 hours then moderate pain.
• Ice, elevate, take pain medication.
• Full weightbearing as tolerated in postoperative shoe from day 3
• Start walking Full weightbearing as tolerated in the surgical shoe
once numbness and pain starts to subside.
• Dressings removed by day 3 but always keep the incision clean and
dry.
• Can wear regular shoe when swelling allows

76. Sreeraj S R
• 0-2 weeks:
• Initiate stationary bicycle
• Active Exercises such as;
• Wiggle toes, Toe Extension, Towel Curl Exercise, Marble
Pickup Exercise, SLR, Clamshells, Side lying Hip Abduction,
Seated heel raise, Toe lift and toe bend over edge of stool
• Self PROM DF/PF toe.

77. Sreeraj S R
• 2-6 weeks:
• Remove shoe and transition to a comfortable, flexible sneaker.
• Start stretching exercises of the big toe, 3x/day for 5 minutes
at a time for another month.
• Scar tissue mobilization
• Stationary bicycle
• Standing heel raise: double and single
• gait training
• Balance and coordination

78. Sreeraj S R
• > 6 weeks:
• Return to function may take up to 3 to 6 months soreness and
swelling may persist for several months.
• Focus on hip/knee/core strengthening
• Patient specific gait training with/without therapist
• DO NOT attempt to gain motion in the planes that were fused
• Driving can be started once able weight bear without
crutches.
• May drive automatic transmission car early when acute
symptoms subside in case of left foot surgeries.

79. Sreeraj S R
• Metatarsalgia is a general term for pain in the area of
the metatarsophalangeal joints.
• The term serves to differentiate pain in the forefoot
to pain in the area under the second, third, and
fourth metatarsal heads.
• Commonly affects the bones as well as the joints at
the ball of the feet.
• Symptoms may occur in one or both feet

80. Sreeraj S R
• The common factor is excessive pressure transmitted through the affected
area due to:
• Repetitive loading of forefoot as in Intense training and high impact
activities
• Wearing high heels
• Improper footwear especially shoes with a narrow toe box
• Excess weight
• High foot arches, bunions, long second toes, lesser toe deformities,
excessive calluses may increase the risk
• Fibrous scar or changes in connective tissue due repetitive injury or
surgical procedures around the fore foot
• Age can thin the fat pad that cushions the ball of the foot over time

81. Sreeraj S R
• Symptoms of metatarsalgia include all or some of the
following:
• Sharp, burning or aching pain in one or more ball of the
foot,
• Sensation of having a pebble in the shoes
• Symptoms worsening on standing, running or walking,
especially while barefoot, and easing with rest
• Occasional burning, tingling or numb sensation in your
toes

82. Sreeraj S R

83. Sreeraj S R
• Assessment of foot shape and associated deformities (hallux valgus, long lesser toes)
• observation of gait and any obvious deformities.
• A leg length discrepancy
• Inspection of the foot for ulcerations and/or calluses under/over the metatarsal heads
• Inspection for swelling, contracture, and abnormal positioning.
• Swelling or signs of inflammation indicative of Synovitis of the toe at the level of the
MTP joint
• Passive Range of motion is documented indicative of degenerative joint disease or an
Achilles contracture.
• Assessment of the gastrocsoleus tightness is done by performing the Silfverskiold test.
• Areas of keratosis or plantar callosities should be palpated for tenderness.
• Examine the stability of the MTP joint by toe translation in a dorsal direction
• Palpation of the web space for pain indicates interdigital neuritis (Morton neuroma).

84. Sreeraj S R
Coughlin MJ (1997)
Algorithm for metatarsalgia Diagnosis

85. Sreeraj S R
• Differential Diagnoses:
• Rheumatoid arthritis or gout
• Morton’s neuroma is a fibrous thickening of nerves that
run along the metatarsal bones.
• Peripheral swelling or fluid build up due to circulatory or
metabolic dysfunction can put pressure on the structures
of the forefoot
• Stress fractures
• Radicular symptoms originating from the low back area

86. Sreeraj S R
• RICE if there is inflammation
• Initial treatment involves relief of the pressure which is
caused by the underlying bony prominence.
• Metatarsal Padding
• Passive and active stretching exercises should be given to the
patients including the stretch of calf muscles and plantar facia.
• Strengthen as weakness in the foot and ankle muscles can
lead to excessive strain on the tissues on the bottom of the
foot including the plantar fascia.

87. Sreeraj S R
• Shaving of the Callus
• Trimming of the callus with a scalpel, callus blade, file, or pumice
stones can be effective in reducing pain associated with chronic
plantar keratosis.
• The goal of surgery is to improve pressure distribution within
the forefoot following failure of nonsurgical measures.
• Chevron osteotomy to correct mild to moderate bunion
deformities
• Oblique diaphyseal osteotomy is performed for more sever
cases

88. Sreeraj S R
• Deformity of the distal
interphalangeal joint in
the foot
• Flexion of the DIP
• Flexor muscles, fascia,
tendons shorten
• Most commonly affects
the 2nd toe; can also be
3rd to 5th
88
https://www.braceability.com/blogs/articles/why-i-had-mallet-toe-surgery

89. Sreeraj S R
• Trauma from impact on tip of the toe
• Constrictive shoe wear
• Inflammatory arthritis, trauma, or a sequela of
hammertoe repair
• High incidence in women

90. Sreeraj S R
• The affected toe will be bent at DIP
• Pain due to rub against footwear.
• May get dorsal toe calluses or corns where a bent
toe presses against another toe or shoe or where the
toe's tip touches the ground.
• In more severe cases difficulty to walk and balance.

91. Sreeraj S R
• The proximal IP joint is
fixed in flexion, while the
distal joint and the MTP
joint are extended.
• The second toe of one or
both feet is commonly
affected
• Women are more likely to
develop hammer toe than
men.
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92. Sreeraj S R
• Constricting shoe wear
• Aging population.
• Longer second toe than the big toe
• Extensor mechanism dysfunction due to its frequent association
with a dropped metatarsal head, flat anterior arch and hallux
valgus.
• May be associated with neuromuscular diseases such as Charcot-
Marie-tooth disease, Friedrich ataxia, diabetes mellitus, and Hansen
disease.
• Inflammatory arthropathies such as rheumatoid arthritis and
psoriatic arthritis

93. Sreeraj S R
• The affected toe will be bent at PIP
• Pain in the affected toe, especially when moving it or
wearing shoes.
• Corns and callouses on top of the affected joint.
• Swelling, redness, or a burning sensation.
• Inability to straighten the toe.
• In severe cases, open sores may develop on the toe.

94. Sreeraj S R
• The IP joints are flexed and the MTP joints
hyperextended.
• The claw toe represents an imbalance
between the intrinsic and extrinsic
muscle units controlling the positioning of
the toe
• Thus, this is an ‘intrinsic-minus’ deformity
that is seen in neurological disorders (e.g.,
peroneal muscular atrophy, poliomyelitis
and peripheral neuropathies) and in
rheumatoid arthritis.
• The condition may also be associated
with pes cavus.
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https://www.braceability.com/blogs/articles/why-i-had-mallet-toe-surgery

95. Sreeraj S R
• Contracture of the long flexors and extensors without
opposition by weak foot intrinsic
• Cavus foot and
• Tight heel cord
• May be associated with neuromuscular diseases.
• Inflammatory arthropathies such as rheumatoid arthritis
and psoriatic arthritis
• Constricting shoe wear

96. Sreeraj S R
• Pain in the forefoot and under the metatarsal heads.
• Walking may be restricted.
• The joints are mobile early and can be passively corrected
• There may be fixed deformities in later stages with MTP joints
subluxed or dislocated.
• Painful corns may develop on the dorsum of the toes
• Callosities under the metatarsal heads.
• In the most severe cases the skin ulcerates at the pressure sites.

97. Sreeraj S R
• Shoes with roomy toe boxes, low heels, and good arch
supports.
• Placing a toe cradle or felt pad or silicone sleeve under
the affected toe to lift the painful tip away from the
ground or sole of the shoe.
• Taping to gently force the affected toe into a normal
position.
• Toe caps, slings, or splints to hold toes in a normal
position, much like taping does.
• Toe exercises

98. Sreeraj S R
• Flexible mallet toe deformity can be corrected with FDL tendon
release using a percutaneous or open approach at the level of the
proximal phalanx.
• Fixed deformities require bony decompression with DIP joint fusion
and FDL tenotomy or transfer.
• Flexible hammer toe and claw toe deformity can be managed with
FDL tendon transfer, but fixed deformity requires PIP resection
arthroplasty or fusion.
• Long-standing claw toe deformity, may require PIP joint arthrodesis.
Distal oblique, segmental shaft, or basal metatarsal osteotomy is
performed to decompress the MTP joint.

99. Sreeraj S R
• Day 0 – 2 weeks
• Patients may go home the same day.
• Pain Control by pain medications and modalities like TENS via a pocket
machine as home program.
• Teach patient about soft dressing to be kept clean, dry and left in place.
• Strict elevation above heart level to minimize swelling and pain.
• Non-weightbearing using crutches or walker is required.
• Heel weightbearing may be allowed for balance only.
• Post-operative shoe should be worn for transfers or when patient is out of
bed.
• Activities are strictly limited during this time.

100. Sreeraj S R
• 2 – 6 weeks
• Suture removal if minimal swelling and reapplication of
forefoot dressing.
• Allowed heel weightbearing only.
• Applying weight to front of foot will bend pins resulting
suboptimal surgical results.
• Continue with limited activities.
• Scar management to be started. Friction message,
underwater ultrasound therapy etc.

101. Sreeraj S R
• > 6 weeks
• Pins are removed.
• Can advance weight to front of foot over next two weeks
in post-op sandal.
• Once comfortable in sandal may transition into
comfortable sneaker.
• Continue Physiotherapy to strengthen the foot and
improve balance.
• No joint mobilization of fused joints

102. Sreeraj S R
1. Pes cavus [Internet]. Physiopedia. 2017 [cited 2021 Apr 27]. Available from: https://www.physio-pedia.com/Pes_cavus
2. Gavin B. “Chapter 21, The Ankle and Foot.” Apley’s System of Orthopaedics and Fractures, by Solomon L et al., 9th ed., London, Hodder Arnold,
2010, pp. 587–624.
3. Pes Planus [Internet]. Physiopedia. 2019 [cited 2021 May 13]. Available from: https://www.physio-pedia.com/Pes_Planus
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5. Princeton Orthopaedic Associates [Internet]. Orthopedics | Orthopedic Surgery | Sports Medicine New Jersey. 2015 [cited 2021 May 12].
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6. Rehabilitation Protocol: Flatfoot Reconstruction [Internet]. ; Available from: https://www.lahey.org/lhmc/wp-
content/uploads/sites/2/2019/01/Flatfoot-Reconstruction.pdf
7. Meda KP, Prem H, McKenzie J. Flatfoot and Tibialis Posterior Reconstruction Surgical Techniques Expected Outcome: [Internet].
https://www.roh.nhs.uk/. The Royal Orthopaedic Hospital; 2021 [cited 2021 May 13]. Available from: https://tinyurl.com/36yhprzw
8. Parekh SG. Foot and Ankle Surgery. 1st ed. New Delhi: Jaypee Brothers Medical Publisher (P) Ltd; 2012.
9. Jointsurgeon. Hallux valgus: A minimally invasive surgery corrects the position of the big toe | Joint-surgeon.com [Internet]. Joint-surgeon.com.
Gelenk-Klinik.de; 2015 [cited 2021 May 25]. Available from: https://tinyurl.com/4d639kfr
10. Physical Therapy Guidelines for Hallux Valgus Correction (Bunion Reconstruction) [Internet]. ; Available from: https://tinyurl.com/6r9hjrzj
11. Gordon D. Hallux Valgus (Bunion) Correction Post Operative Rehabilitation Protocol [Internet]. https://www.davidgordonortho.co.uk/. 2013 [cited
2021 May 25]. Available from: https://www.davidgordonortho.co.uk/resources/Hallux-Valgus-Surgery-Post-Op-Rehab-David-Gordon.pdf
12. Forefoot Pain (aka Metatarsalgia) [Internet]. Rebalancetoronto.com. 2018 [cited 2021 Jun 3]. Available from:
https://rebalancetoronto.com/forefoot-pain-metatarsalgia/
13. Coughlin MJ. (i) Metatarsalgia: a symptom, not a diagnosis. Current Orthopaedics. 1997 Jan;11(1):1–10.
14. Hammer, Claw, and Mallet Toes | Michigan Medicine [Internet]. Uofmhealth.org2015 [cited 2021 Jun 4];Available from:
https://www.uofmhealth.org/health-library/hw143427
15. Shirzad K, Kiesau CD, DeOrio JK, Parekh SG. Lesser Toe Deformities. American Academy of Orthopaedic Surgeon. 2011 Aug;19(8):505–14.
16. Marks RM. Lesser Toe Correction [Internet]. Googleusercontent.com2021 [cited 2021 Jun 4];Available from: https://tinyurl.com/j67vf78n