Ryan Fitzgerald, DPM PRESENT RI Associate Editor Hess Orthopedics & Sports Medicine, Harrisonburg, Virginia

Case Presentation:
Collapsing Pes Planovalgus
in a 58 y/o Patient (Part 1)

HPI: The patient is a 58-y/o male who presents complaining of significant pain along the medial ankle and medial arch of his left foot.  The patient states that he has noticed his arch collapsing “over the last couple of years” but that it has only become painful over the last 4-6 months.  The patient states that he feels better with shoes that have high arches in them, and relates that he was seen by another podiatrist who fitted him for orthotics. The patient believes that the orthotics help somewhat, although he still relates to pain and loss of function.  The patient denies any recent hospitalizations or changes to his medical history, and denies nausea, vomiting, chest pain, shortness of breath, calf pain, or any other symptoms.

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PMH: HTN, hypercholesterolemia

PSH :cholecystectomy, previous ORIF left wrist

Social: denies tobacco, relates to occasional ETOH, and drinks caffeine daily

ALL:  NKDA

Meds: Liptor, HCTZ, Lisinopril

PE:  upon physical exam, the patient demonstrates a significant collapsing pes planovalgus foot type (Left > Right).  Pedal pulses are palpable and graded +2/4 bilaterally, CFT < 3 seconds.  There is hair growth noted on the leg to the distal 1/3 of the tibia bilaterally.  The patient demonstrates bow-stringing of the tibialis anterior tendon (Fig.1) Muscle strength is graded +5/5 in dorsiflexion/plantarflexion, however there is weakness noted with resisted inversion that is more pronounced on the left. The patient demonstrates pain with palpation along the course of the posterior tibial tendon on the left side, with the point of maximum tenderness located approximately 3 cm from the insertion on the navicular.  In resting calcaneal stance position (RCSP), the patient demonstrates a significant rearfoot valgus (Fig. 2) that does not reduce with toe raise (Fig. 3).

Figure 1:  The patient demonstrates a collapsing pes planovalgus deformity of the left foot with collapse of the medial arch and bow-stringing of the tibialis anterior tendon.

Figure 2:  In RCSP, the patient demonstrates significant rearfoot valgus on the left. The right foot also demonstrates a rearfoot valgus, however it is less severe.

Figure 3:  With toe-raise, the rearfoot valgus of the left foot fails to reduce.  Notice that inversion of the rearfoot does occur with the right foot.  This maneuver also generates significant pain in the left foot.

Radiographs: Plain film radiographs of bilateral feet demonstrate increased talar declination on the lateral x-ray with collapse of the midfoot and an increase in meary’s angle. (Fig 4) On the AP, there is a decrease in talonavicular coverage noted (Fig. 5).

Figure 4:  There is collapse of the midfoot with an increase in Meary’s angle noted.

Figure 5: On the AP radiograph, there is a decrease in talonavicular coverage noted.

Considering the history, radiographic data, and clinical exam, how would you proceed in the management of this challenging patient? Join in the eTalk and lets us know your thoughts. We'll share your ideas and folllow up with the conclusion of this case presentation, in next week’s Residency Insight.

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