Common Deformities: Flat Feet, Hallux Valgus, Patella Alta (High Riding Patella)

Flat Feet

**Medical Professionals can additionally see the PowerPoint presentation:

The two arches (longitudinal and transverse) on the inside of your feet are flattened, allowing the entire soles of the feet to touch the floor while standing.

A common and usually painless condition, flatfeet can occur when the arches don’t develop during childhood. In other cases, flatfeet develop after an injury or from the simple wear-and-tear stresses of age causing ligament laxity.

Flatfeet can sometimes contribute to problems in ankles and knees because the condition can alter the alignment of legs. Treatment is usually necessary for symptomatic flatfeet if there is pain but follow up with your Doctor in a serial  and a special  ‘bakshi program of flatfoot exercises’ designed by Dr Kapil Bakshi (Available after clinical assessment and consultation).

Hallux Valgus

Hallux valgus is a deformity of the foot with a medial deviation of the first metatarsal and lateral deviation and/or rotation of the hallux(big toe) with or without medial soft-tissue enlargement of the first metatarsal head(Bunion). This condition can lead to painful movements of the joint or difficulty with footwear and overlapping or under lapping toes.

Contrary to common belief, high-heeled shoes with a tight small toe box do not cause hallux valgus, tight shoes can cause medial bump pain and nerve entrapment.

Hallux valgus is known to have numerous causes which include biomechanical, traumatic, and metabolic factors. Gouty arthritis, Rheumatoid arthritis, Psoriatic arthritis, Connective tissue disorders such as Ehlers-Danlos syndrome, Marfan syndrome, Down syndrome, and ligamentous laxity are common causes.

Further assessment includes checking

Hip internal/external rotation
Genu valgum/varum
Tibial torsion
Ankle joint dorsiflexion
Subtalar joint range of motion (ROM)
Midtarsal joint ROM
Neutral calcaneal stance position
Resting calcaneal stance position
Forefoot/rearfoot varus or valgus

Laboratory Tests

Uric acid
Erythrocyte sedimentation rate
C-reactive protein
Antinuclear antibody, Anti-CCP
Rheumatoid factor


A night splint or a dynamic splint can be prescribed to move the great toe to medial. After the end of growth, adequate correction is no longer possible and conservative treatment is restricted to alleviation of symptoms.

Dynamic Splints / Night Splints / Toe Separators and sole inlays can be used

Consult your Orthopaedic surgeon for the most appropriate footwear and pain relief program designed and tailored individually.

Once hammer toes or claw toes have developed, however, surgery is necessary.

Patella Alta (High Riding Patella)

The Insall-Salvati ratio or index is the ratio of the patella tendon length (LT) to the length of the patella (LP).

Insall-Salvati ratio

This can be measured on a lateral knee x-ray or sagittal MRI. Ideally the knee is 30 degrees flexed.

Distance lines used to calculate Insall-Salvati ratio (see figure)

The Insall-Salvati ratio (LP:LT) is considered normal between 0.8 and 1.2:

patella baja: <0.8 (perhaps <0.74)
patella alta: >1.2 ( perhaps >1.5)
More recent literature 2 suggests that the true normal range is more forgiving: from as low as to 0.74 to as high as 1.50.


Modified Insall-Salvati ratio

Also applied on a lateral 30 degree flexed knee radiograph, the modified Insall-Salvati ratio is measured slightly differently:

A: distance from the inferior margin of the patellar articular surface (as opposed to the lower pole of the patella itself) to the patellar tendon insertion
B: length of the patellar articular surface (see diagram).
Modified Insall-Salvati ratio = A/B

The modified Insall-Salvati ratio is considered normal around 1.25, abnormal when >2 which is considered diagnostic of patella alta.


Supervised Physiotherapy by your doctor helps in most cases, other orthotic supportive

treatment may occasionally be required with or without NSAIDS.