term flatfoot is a subjective term that is used to describe a foot with a decreased or absent
arch. Flatfeet can be acquired or hereditary. The vast majority of
flatfeet are hereditary. Just as we inherit facial features, eye color and
hair color of our parents, we also inherit a set of bones and joints that
function much like those of our parents and grandparents. The vast
majority of flatfeet are benign and will never have a significant impact on the
person, their lives or their occupation. Occasionally
though we see specific types of flatfeet that are real trouble makers.
Let's talk about those in a little more detail.
Pediatric flatfoot is a problem seen often in a podiatrists
office. Children usually don't have the verbal skills to express themselves
with any degree of accuracy regarding medical problems. But children will give us indirect clues or indications of a problem. They'll ask to be
carried or they'll want their legs and feet to be rubbed. And in the
case of a symptomatic flatfoot, children will
tend to express these complaints more so after they've been active. Pediatric flatfoot symptoms are due to the mechanical inefficiency of the
flatfoot. Simply put, it just takes more work to walk with a flatfoot.
Therefore, kids with flatfeet have to exert more effort during a day to
keep up with the other kids.
Although most pediatric flatfeet are
asymptomatic, there are several different types of pediatric flatfeet that cause
pain and can
be of significant concern. There are several congenital (from birth)
deformities that we see that result in flatfeet. One of the more
common congenital deformities is called a
tarsal coalition. Tarsal refers to the bones of
the rear portion of the foot and coalition refers to a bridge. What
happens in cases of tarsal coalition is that a coalition or bridge of
bone forms between two bones, limiting the range of motion of the joints
of the foot. The end result is a rigid, painful flatfoot. This is
a challenging condition to diagnosis in young children. The challenge lies in the fact
that the radiographic findings of tarsal coalition don't become evident until the late teens. Part
of the diagnostic challenge lies in the fact that the bridge of bone in
young children is made of fibrous material and cannot be seen on
x-ray. As the patient matures, the fibrous bridge begins to ossify
(turn to bone). As this ossification progresses, the foot becomes
markedly rigid and painful. MRI can be very helpful in the diagnosis of
a tarsal coalition.
The inherited adult flatfoot can have
many of the same problems that we've already discussed in
children. The majority of adults with flatfeet simply complain of fatigue and an
inability to get through the day comfortably. These are the same
kids that we've just talked about, only they've grown up to become
A second type of adult flat foot is an acquired flatfoot. An acquired flatfoot can be due to many different reason
including trauma, arthritis and
tendon rupture. Acquired flatfeet can be unilateral
or bilateral and can be some of the more
challenging flatfoot cases to manage. The most common symptomatic
acquired flatfoot that I see is due to
posterior tibial tendon dysfunction (PTTD).
The posterior tibial tendon originates beneath the calf, descends along the
inside of the ankle and inserts into the arch. Its' primary function is to
support the height of the arch. When this tendon is damaged and becomes
'dysfunctional' the bones and joints of the arch begin to collapse. PTTD is more
common in women and is seen with increasing frequency with increased age.
Treatment of Flatfeet
of pediatric and adult flatfeet depends upon each individual patient's
symptoms. Pain should be the
primary motivation for treatment. Treatment starts with a
simple conservative approach in most cases.
Initial treatment of pediatric flatfeet starts with
pediatric arch supports and shoe
modifications. Arch supports can be OTC or prescription. Shoe
modification can be performed by your pedorthist or shoe repair shop and
include an arch cookie (glue in support) and reverse Thomas heel.
A traditional Oxford shoe is the most common style of shoe that can
accommodate these modifications. The key to initial treatment is to try the simple tricks and see
how well they
work. How do you know that they're working? You'll simply
see a decrease in symptoms. The other consideration with kids is
that they're going to grow out of things so quickly. I think it's
money well spent to discuss your concerns with your podiatrist or
They'll be able to recommend a treatment plan that may be significantly
more cost effective for your child in the long run.
Initial treatment of the adult
flatfoot is much the same as we've discussed with children. Try
the easy things first such as
an OTC rigid carbon graphite orthotic and eurocomfort shoes.
You'd be amazed at what a decent pair of comfortable shoes can do to
change a persons life. If the symptoms of a
respond to conservative care, consult your podiatrist. I would
also like to stress that early treatment of some of the conditions that
we've discussed, like
PTTD, is very important. We've
discussed the fact that PTTD is due to failure of the posterior tibial
tendon. In the early stages of this condition, the tendon is inflamed
and can be corrected. If the condition is allowed to progress, the
tendon will eventually rupture leading to a surgical correction that can
be quite extensive. Conservative care of adult flatfeet includes
traditional Oxford shoes,
and Rx braces.
glance, flatfoot surgery would seem fairly simple with the primary
surgical objective being to raise the arch. But in actuality
it's much more complex than that. Much of the stability of the
foot comes from the bones of the rearfoot. If a house has a bad
basement, the rest of the house is in jeopardy. The same holds
true for the foot. A faulty rearfoot jeopardizes the stability of
the rest of the foot.
In addition to correcting the arch, we also need to
consider how to restore the center of gravity over the foot. Quite often in flatfoot
cases we see the arch collapse and the foot rolls in forcing the center
of gravity to be carried somewhere out over the inside of the foot.
That's a very important consideration when repairing flatfeet.
Flexible vs Rigid Flatfeet
When a patient is evaluated for flatfoot surgery, one of the first
consideration made in surgical planning is whether the foot is flexible or rigid. Determining
flexibility vs rigidity is a bit subjective. Your doctor will manipulate
the foot to determine the degree of flexibility. This determination is
important in defining the surgical treatment plan. Flexibility is assessed
in all three cardinal planes; frontal, transverse and sagital. Flexible
flatfeet can be treated with a number of procedures that are ambulatory with
little post-operative disability. Rigid flatfeet, on the other hand,
require a higher intensity of care with subsequently longer period of post-op
Surgical Treatment of Flexible Flatfeet
common procedure used to treat flexible flatfeet involves placing a small
metal implant in the subtalar joint
to 'wedge' the foot and ankle into a more stable position. This procedure is referred
to as a subtalar arthroeresis (STA-Peg procedure). Arthroeresis is not as invasive as other forms
of surgical arch reconstruction, but may only be used in select cases of
flexible flatfeet. Subtalar arthroeresis is often referred to as
an internal cast, supplying support from within the subtalar joint. Sub
talar arthroeresis is often performed with a procedure to lengthen the
calf muscle and/or Achilles tendon. These procedures include an
endoscopic gastrocnemius recession and/or Achilles tendon lengthening.
The following images show the steps used to perform a STA-Peg
procedure. A STA-Peg procedure was one of the earliest methods of subtalar
arthroeresis. Image 1 shows pre-operative planning marking the boundaries of
the peroneal tendons and intermediate dorsal cutaneous nerve. In image 2
wee see the peroneal tendons retracted down and the intermediate dorsal
cutaneous nerve retracted up. Image 3 show entry into the subtalar joint.
Image 4 and 5 show preparation of the of the subtalar joint for the implant.
And image 6 shows the implant in place. The capsule of the subtalar joint
would be closed and skin reapposed with several non-absorbable sutures.
patients can bear weight on the foot the same day. STA-Peg implants come
in three sizes. Image 7 shows the implants and their corresponding
The following video shows subtalar arthroeresis being performed
using a conical implant. There are a number of companies who manufacture
conical subtalar implants. This procedure is performed on an ambulatory
basis, using either sedation and a local anesthetic, or general anesthesia.
This method of subtalar arthroeresis take about 20 minutes to complete.
Most patients are able to bear weight on the foot the same day.
The next procedure that we'll describe to treat a flexible flatfoot is a
modified Kidner procedure. The pictures below show the steps used to
perform a modified Kidner procedure. A modified Kidner
is often used in conjunction with other procedures to correct a flatfoot
deformity. A modified Kidner procedure is also used in cases of a
symptomatic os tibial externum (accessory bone of the medial arch as seen in the
image to the left).
Image 1 shows the planned approach with the leg to the left and
toes to the upper right. Image 2 shows deep tissue dissection and
identification of the posterior tibial tendon sheath. Images 3-5 show
dissection of the os tibiale externum from its' investment from within the
posterior tibial tendon. Image 6 shows repair of the posterior tibial
tendon with non-absorbable suture. Image 7 is final skin closure.
Image 8 shows the articular surface of a large os tibial externum.
Os tibiale externum is found in 15% of the general population and functions in a
way similar to your knee cap (patella), enabling its' associated muscle and
tendon to function more effectively. The os tibiale externum articulates
(forms a joint) with the navicular bone. Pain due to a symptomatic os
tibial externum is often due to arthritis at this articulation. The forceps
point to a focal area of degenerative change consistent with may be called
osteochondritis dessicans. Osteochondritis dessicans describes erosion of
cartilage that results in arthritic changes.
A modified Kidner procedure is performed on an out-patient
basis using general anesthesia and a thigh tourniquet. The
procedure takes approximately an hour to perform. Inherent in the
term modified, a modified Kidner may include several additional steps
not described in these pictures. Additional steps may include
tendon transfer or tenodesis (anchoring the tendon to the bone).
Post-op care may include a bandage, splint or cast. Some patients
may ambulate following this surgery, others may not. The size of
the os tibiale externum dictates whether a patient may walk post-op or
not. The percentage of space taken up by the os tibiale externum
within the tendon may be significant enough that immediate weight
bearing would result in failure of the posterior tibial tendon.
Your surgeon will be able to determine when you can return to ambulation
during the procedure.
The long-term success or failure of a modified Kidner procedure
can depend upon the treatment of the associated flatfoot. If the
flattening of the foot is allowed to continue following a modified Kidner,
continued stress will be placed upon the posterior tibial tendon. In some
case, this will lead to failure of the PT tendon. Therefore, it is
imperative to address the flatfoot at the time a modified Kidner is performed.
A common procedure that would accompany a modified Kidner would be subtalar
arthroeresis, medial column arthrodesis or lateral column lengthening.
Surgical Treatment of Rigid Flatfeet
treatment of the rigid flatfoot requires making structural changes to the bones
and joints of the foot. The primary focus of these procedures is to realign
the center of gravity of the body over the foot. These structural changes
can be made in one or all three of the cardinal body planes as described above.
The majority of rigid flatfoot cases require an osteotomy of the
heel to realign load bearing on the heel. Calcaneal
osteotomies are used to correct frontal plane flatfoot deformities. An
osteotomy of the heel is a surgical break through the body of the heel.
This procedure is normally completed through a 3-4 cm incision on the lateral
aspect of the heel. The heel bone is then shifted medially (towards the
arch of the foot) and fixated with a screw or pin. This procedure carries
many names including a calcaneal slide procedure or calcaneal off-set osteotomy.
A calcaneal slide procedure needs to be performed in a hospital setting under
general anesthesia. 6-8 weeks of non-weight bearing casting is required
following this procedure.
Sagital plane flatfoot deformities are address with either an
Achilles tendon lengthening or endoscopic gastrocnemius procedure.
Clinical assessment of most adult flatfeet will show that
present and needs to be addressed by either of these two procedures.
Medial column fusions are common in the treatment of a rigid
flatfoot. Medial column fusions address frontal and sagital plane deformities.
The location for the medial column fusion is determined on x-ray. In a lateral x-ray of the foot, the lowest portion of the arch is identified.
The low section of the arch will typically be the talo-navicular joint or the
navicular cuneiform joint. One or more of these joints is fused in a
medial column fusion. These procedures need to be completed in a hospital
stetting under general anesthesia. A 6-8 week period of non-weight bearing
casting is common.
Another method employed in treating flatfeet include a procedure
called an Evans Procedure. An Evans
is used to correct abduction of the forefoot. Abduction is a transverse plane
deformity. The test used to determine
the amount of abduction of the forefoot is called a 'too many toes sign'.
In cases of extreme forefoot abduction, when the foot is viewed from the back,
the 4th and 5th toes will be seen peeking out along the lateral aspect of the
foot. The Evans procedure is used to wedge the foot back to a straight, or
non-abducted position. An Evans procedure uses a bone graft to wedge the
distal calcaneus, in effect lengthening the lateral column of the foot. An
Evans procedure may be used in conjunction with any number of other flatfoot
Rigid flatfeet are also treated with a number of different tendon
transfers. The most common tendon transfer used in flatfoot surgery is the
transfer of the flexor hallucis longus tendon to the posterior tibial tendon.
The posterior tibial tendon is the primary tendinous support of the medial arch.
The posterior tibial tendon often fails in cases of flatfoot. Tendon transfers
such as this serve to reinforce the PT tendon.
The treatment of a rigid flatfoot deformity can be challenging for
both surgeon and patient. When planning rigid flatfoot correction, it's
important that patients understand the degree of disability associated with the
procedure. It is not unusual for many patients to bee off work for a
period of 6 months or more when undergoing a rigid flatfoot repair.
Abduction (abducto) - a motion of the forefoot
out and away from the mid-line of the body
Tarsal coalition - a bridge of bone that inhibits
normal bone growth in the foot and contributes to a flatfoot
Valgus - a motion of the foot out and away from
the mid line of the body
The anatomy of a flatfoot is much
the same as a 'normal' foot. The difference between flat and normal arches
is simply the alignment of the structure within the foot. Differences in the structure of the foot can
been seen on a lateral x-ray where a drop or fault is found in the arch of the
foot. The fault can be a vary in location and severity.
One anatomical issue common to most flat feet is
Equinus limits the range of motion at the ankle and is a primary contributing
cause to most pediatric and adult flatfeet.
The single most common contributing factor to
flatfeet is equinus. Equinus refers to a tight calf and Achilles
tendon. The term equine is Latin for horse. This term is used
because horses walk on their toes and don't allow their heels to touch the
ground. When the term equinus is applied to lower extremity biomechanics, it
means that the calf and Achilles tendon limit the normal range of motion of the
Equinus can be a deforming force that is applied to the
foot from the time a child begins to walk. If the tightness of the calf
and Achilles tendon are significant, and the arch is resilient and strong enough
to withstand the force of the calf, the child will be a toe walker. But in the
majority of cases, the arch is weak and will collapse or deform under the
biomechanical load generated by the calf. The collapse of the arch due to
equinus provides a small amount of dorsiflexion of the foot (toes towards the
shin) to enable normal walking.
Symptoms of a flatfoot may include fatigue, pain
and an inability to keep up with others for any distance or time on your
feet. The symptoms of flatfeet depend upon many
variables. These include;
The severity of the flatfoot.
The rigidity vs flexibility of the foot. The time spent on the feet in recreation and work. The type of shoes and inserts used to help support the foot. General physical condition and body weight/body mass index.
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