Novokuznetsk Scientific Practical Center of Medical Social Expertise and Rehabilitation of Disabled Persons,

Novokuznetsk Prosthetic Orthopedic Enterprise,

Novokuznetsk, Russia

  

Platypodia is one of the most frequent static deformations of human locomotor system. According to the data from different authors it is found in 15-80 % of population [1, 2, 3].

There are congenital and acquired platypodia. Congenital platypodia is a very rare event [4]. According to the etiologic principle, acquired platypodia is divided into static, rachitic, paralytic and traumatic platypodia. In their pure form none of the above mentioned causes provide the large-scale pathology, which pediatricians and pediatric orthopedists can observe.

Wide spreading of platypodia is often related to perinatal pathology of central nervous system [5]. It is unacceptable to exclude the significance of chronic smoldering forms of rickets for development of such pathology among the pediatric population of the large industrial cities. Changing motor conditions and wearing improper shoes altogether form non-optimal conditions for work of the muscles, which form and support arch of the foot.

Meanwhile, in the human body the foot fulfills support, spring, balancing and pushing functions. The negative influence of platypodia on all of these functions was postulated [4]. In the growing body the formation of feet ranges with formation and spreading movement patterns. It is considered that children with platypodia are less coordinated, with worse counterpoising and no so slinky gait (often slapping) as in healthy children of similar age. Such children have worse characteristics in learning run and jumping compared to peers; full coordination exercises are more difficult for them and are not so esthetic.

Weak maturity of foot spring function has negative influence on the whole body: the lower limb joints, spine, internal organs and the brain become susceptible to concussions during walking, run and jumping.

Weak muscles of the leg and the foot result in fast fatigue. Therefore, children get tired quickly, do not like long walking; younger children want to be taken in one’s arms, avoid walking and outdoor games. Commonly, long term standing is accompanied by pain feelings in muscles and the joints of the lower extremities.

At the same time, everyone performing diagnostics and treatment of platypodia deals with types of flatfoot, when patients have no specific complains and long motion activity limitations, with possibilities for sport activities. Therefore, foot arch flattening is accompanied by remarkable deterioration of spring, balancing and pushing functions. Not all people have clear parallel between degree of decreasing arch of the foot and worsening its function.

However, during platypodia diagnostics one should consider mainly reducing foot arch. The common examination techniques for foot arch - examination, plantopodography, X-ray – are mainly oriented to diagnostics of foot form and square of its contact with footplate [6]. It is reflected in the classification of platypodia.

Using techniques of dynamography and posturography one can assess supporting reactions during motion, distribution of pressure within the limits of support contour during standing. Not only the foot is important for realization of these functions, but the body at whole. Therefore, it is difficult to separate the degree of foot function loss with these techniques, and usually they are not used for establishing platypodia diagnosis.

Using DiaSled complex allows objective and qualitative assessing the foot function: to get pressure distribution pattern under the foot during movement and without it, to perform full evaluation of spring, balancing, supporting and pushing functions with results of analysis of pressure dynamics for different parts of the foot during postural and locomotor tests.

The aim of the study was performing the analysis of relationship between decreasing foot arch and function loss.

 

MATERIALS AND METHODS

The study was performed at the basis of the prosthetic orthopedic enterprise, Novokuznetsk, in 2010-2013. During this period 380 persons with platypodia diagnosis were examined. Out of these individuals the group of 60 patients with platypodia of degree 3 was developed: 14 male patients, 46 female patients, age of 4-81. All patients were distributed into the age groups as following: age of 4-18 – 20 persons, age of 19-40 – 15 persons, age of 41-60 – 17 persons, age > 61 – 8 persons.

All patients received the clinical examination, plantopodography and investigation with DiaSled complex. This is the standard examination, which is performed for all patients with the same diagnosis who visited Novokuznetsk prosthetic orthopedic enterprise. The performed study corresponds to the standards of Helsinki declaration “Ethical principles of conduction of scientific medical studies with human participation” and the rules of clinical practice in Russian Federation. The informed consent for analysis of personal data was received (protocol #1 from the session of the ethical committee of Novokuznetsk Scientific Practical Center of Medical Social Expertise and Rehabilitation of Disabled Persons, 30.01.2014).

The following information was received from life history: presence of similar pathology in relatives, professional activities, physical and sport activity, diseases (spinal osteochondrosis, lower limb joint osteoarthrosis), genesis of which is characterized with significance of decreasing foot spring function.

The following information was received from disease history: disease duration, course of disease, its influence on limiting motion activity, life style, choice of job, foot wear selection.

During examination the special attention was given to deformation of the spine and gross joints, foot form, foot arch flattening, presence of hammer finger deformation, abduction of the pollex, calcaneal bone deformation.        

Plantopodography was performed with PlantoScan module, which, on the basis of visual and graphic calculated estimation of different lineal and angle indices, allows indirect estimating mutual arrangement of foot sections and the height of internal longitudinal arch (coefficient of anterior department, coefficient of spread of anterior department, Chopart joint angle, angle of declination of the first toe, lineal index of arch height).

DiaSled examination included investigation of standing and walking. In motionless state the analysis included position of general pressure center, presence of diagonal curving, load asymmetry between extremities, disorder of zonal distribution of load, support preferment. During motion the analysis included shift of general pressure center, symmetry of trajectory of pressure center for right and left foot, structure of integral load chart for each foot, rhytmicity, fluidity and expression of anterior and posterior pushes, presence of load primary minimum, roll structure, local hyperpression, step variability.

 

RESULTS

Among 60 persons 47 ones had complaints of fast fatigue during standing and walking, pain in feet, pain in calcaneal region, feet deformation, edema in ankle-joint region, increasing feet sizes, pan in leg and knee joint. 30 patients had no complaints. The further analysis was performed in the groups. The persons with complaints were included into the first group, without complaints – in the second one.

The first group included 7 male and 40 female patients. The age of the patients varied from 4 to 81, the mean age – 43.

Platypodia was injury consequence in 2 men (calcaneal bone fracture, fracture ossa metatarsi fracture). 5 male children had platypodia and scoliosis of degrees 1-2. Their parents noted the sedentary lifestyle of the boys, avoiding walking, running, jumping from early childhood. The other members of the family had no platypodia.

38 women remembered about platypodia in their parents, grandmothers and grandfathers that indicated a possibility of genetic predisposition. Two women noted that platypodia diagnosis was confirmed in their adolescence period, but the complaints of fast fatigue, feet and leg pain appeared lately – after age of 40.

All women of this group wore improper foot wear: uncomfortable, confined, with bad arching. The women noted that in case of wearing high-heel shoes the foot slid from the heel to the tip of foot wear and it was accompanied by discomfort feeling in region of foot digits, spreading anterior foot department, decreasing stability during standing and walking. All questioned women had sedentary lifestyle, but only 18 persons had indicated the association such lifestyle with discomfort in the feet during movement. All women were in premenopausal and postmenopausal periods, all had previous treatment of osteochondrosis and arthrosis deformans of gross joints.

The examination of the feet of all studied adults of this patients found the following: longitudinal arch applanation, anterior feet spread, calvus in the region of heads of 2^nd, 3d and 4^th metatarsal bones, great toe abduction, hammer-shaped deformation of 2^nd, 3d and 4^th toes, knee joint defiguration, lumbar lordosis flatness.

The  plantopodograms (Fig. 1A) showed increased coefficient of anterior feet spread from 0.45 and more, decreased angle of Chopart joint to 140-155°, increased lineal value of arch height (>0.83), decreased podometric index <25 %, changed valgus deviation of the axis of the calcaneal department in 8 persons with tendency to decrease and in 29 persons with tendency to increase. 10 persons had no deviation of the calcaneal department of the foot.

According to the results of static examination with DiaSled all patients of this group showed displacement in frontal, sagittal and in both planes of location of the general pressure center, presence of zonal distribution of load: hyperpression in plane of the heads of middle metatarsal bones, evident support preference with the right or the left foot (Fig. 1C).

The walking examination showed disorders in load distribution between the feet and between the individual parts of the foot during different stages of walking. Disorder character depended on prevailing pathology.

12 patients with longitudinal platypodia as dominating pathology had increased load in the region of internal department of the heel and the middle department of the foot during anterior push, in the region of anterior external department of the foot during posterior push. In case of transverse platypodia the sequence of roll did not change, but duration of posterior push increased, and the load in the heads of metatarsal bones rose. 18 patients with evident pain syndrome had repetitive load in the heads of metatarsal bones that increased duration of posterior push.

19 patients noted shift in the trajectory of the general pressure center in the frontal plane, 16 patients – in sagittal one. 12 persons had displacement of the trajectory of the general pressure center in two planes (Fig. 1d). Medial or lateral displacement of the pressure center under the feet (Fig. 1E) and increased radius of curvature of the pressure center trajectory was noted in all examined patients of this group.

Disorder of structure of the integral load diagram was more expressed on one of the feet in all patients. It resulted in asymmetry of the integral load diagrams. Disorder of expressiveness of anterior and posterior pushes was in view of decreased maximal amplitude, flatness and appearance of several maximal points. 23 patients had absence of head minimal load. In 24 persons the integral load diagram was in view of one-humped flat-topped curve topped (Fig. 1f).

Figure 1

The example of foot load distribution in a patient of the first group: a – computer plantopodogram; b – load distribution between the feet during standing; c – zonal distribution of feet load during standing; d – load distribution between the feet during walking; e – zonal feet load distribution during walking; f – the diagrams of interval load during walking.    

 a

b  c  e

d f

The second group included 13 persons at the age of 12-38, 7 male and 6 female patients. The male participants were adolescents with active life. They noted such hobbies as football, hockey, dancing and downhill skiing. They were given platypodia examination performed by the call-up commission orthopedists, or they had visit upon an initiative of their parents who found feet deformation. All representatives of this group were characterized by heredity burdened with platypodia at least in one parent. Besides flat valgus feet deformation, all patients had S-shaped scoliosis of degree 1-2.

All women of this group required examination because of cosmetic defect of the feet. They had active life, used foot wear with high heel, and, sometimes, with arching, and, from time to time, flat shoes. All they had heredity burdened with transverse oblique platypodia through the female line. During the retrospective interview nobody could remind of feet pain during periods of rapid growth or pregnancy. Nobody limited motion activity because of fatigue or feet pain. There were no complaints of pain syndromes in osteochondrosis and lower extremity arthrosis. Nobody had treatment of these diseases.

During examination the rough changes in feet shape were found in all patients of this group: longitudinal arch flattening, spread anterior department, clavus on the heads of the second and third instep bones, the first toe abduction, osteochondroma in the region of the first instep bone.

The plantopodograms (Fig. 2a) showed: increased coefficient of spread anterior department of the feet from 0.45 and more, decreased angle in Chopart joint about 140-155°, increasing linear value of arch height above 0.83, decreased podometric index less 25 %, change in valgus declination of calcaneal department axis with the tendency to decrease in 4, increase – in 9.                               

According to the static examination with DiaSled: in the frontal plane the general pressure center is located in the middle line, in the sagittal one – slightly displaced dorsad that means normal range. There is no a diagonal sag. Asymmetry between the limbs is non-significant, within the normal range. Support preference is non-significant and within the difference between the pushing leg and switch one in a healthy individual (Fig. 2b). The moderate hyperpression was found in the region of the heads of the middle instep bones in one foot (Fig. 2c). The dynamic study showed that pressure center curves of the feet were smooth symmetrical lines along the longitudinal axes of the feet. There is no shift in pressure center curve (Fig. 2d). There is hyperpression in the region of the heads of the middle instep bones that indicates spread anterior arch (Fig. 2e). The interval load diagrams are smooth and symmetrical. Anterior and posterior pushes with the feet and the main minimal load are clearly defined (Fig. 2f). The posterior push is more expressed during fast walking (normal range).

 Figure 2

The example of foot load distribution in a patient of the second group: a – computer plantopodogram; b – load distribution between the feet during standing; c - zonal distribution of feet load during walking; d – load distribution between the feet during walking; e – zonal distribution of feet load during walking; f – the diagrams of interval load during walking.  

  a

b ce

df

DISCUSSION

The examination included 60 patients with platypodia of degree 3. After questioning all examined patients were separated into two non-uniform groups. The patients of the first group (3/4 of the patients) had specific complaints and adapted their lifestyle with consideration of limitations associated with feet pathology. The representatives of the second group also had decrease in arch and the evident feet deformations within the range of platypodia of degree 3 which were similar with the first group, however, without negative influence on their lives.

The causes of the differences were evident after comparison of the results of feet function examination. It emerged that the patients of the first (bigger) group had feet function disorders. Disorders in support and balancing functions of the feet during standing were in view of shifted position of the general pressure center, diagonal sag, load asymmetry between the limbs, impaired zonal load distribution and presence of evident support preference.

The disorders of spring pushing and balancing functions during standing were displaced general pressure center in the frontal and sagittal planes, shifted pressure center under the feet, increased radius of pressure center trajectory curvature, disordered structure and asymmetry of integral load diagram. All examined patients had zonal hyperpression and different types of impaired sequence of foot roll.

The results of examination of these patients correspond to the orthopedists’ expectations. Foot load distribution is impaired during standing and walking. As result, foot functions suffer, pain appears and load changes in the upper skeletal departments during motion that provokes development of gross joint and spine pathology.

In the patients of the second (small) group, despite of evident feet deformation, static and dynamic load distributed like in healthy individuals. Therefore, foot arch flattening did not result in complaints and limited motion activity. This group included the patients at the age < 40. Among the older patients of the first group 2 individuals had platypodia in their adolescence, but specific complaints appeared after the age of 40.

Therefore, decrease in foot arch height and deformations do not result in foot function disorders in all cases. In our study the quarter of the patients with platypodia of degree 3 had no complaints, and the examination showed saved feet functions. However, over the time, foot deformation results in function loss. As the confirmation, we note that only young patients had no complaints, but among the older patients two individuals had their long period of life without complaints.

 The important conclusion follow: during estimation of medical limitations for physical load it is necessary to perform examination of both shape and function of the plain foot. Individuals with platypodia need for selection of appropriate foot wear regardless of complaint presence.