How and why does a person get flatfeet? Those are the two important questions to ask when differentiating between the simple (non-pathological) and the not so simple (pathological) types of flatfeet. The most common flatfoot is a simple asymptomatic flatfoot. This type of flatfoot is present when a child first begins to walk. Many of the moms that come in the office joke that their child has their dad's feet indicating that he also has no arch. We don't actually inherit this type of flatfoot per say, but we inherit bone structure and biomechanical traits that are very similar to those of our parents. It's really no different than the way we inherit the color of our eyes or the color of our hair. We'll walk and move much like our parents do and if they have flatfeet we probably will too.

Children are challenging patients to treat because they don't have the ability to express themselves and tell you where or how they hurt. Children will give us indications of a problem. They'll ask to be carried or want their legs and feet to be rubbed. A child with the common type of flatfeet that we've already mentioned will express these complaints, particularly when they've been very active. These symptoms are due to the mechanical inefficiency of the flatfoot. 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 can be of significant concern. There are a number of specific congenital (from birth) deformities that we see that result in flatfeet. One of the more common 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.

The 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 talked about, only they've grown up.

Occasionally adult patients will develop another type of flatfoot referred to as an acquired flatfoot. An acquired flatfoot can be due to many different reason such as trauma, arthritis etc. Acquired flatfeet can be some of the more difficult flatfoot cases to manage. The most common symptomatic acquired flatfoot that I see is due to a condition called posterior tibial tendon dysfunction (PTTD). The posterior tibial tendon originates beneath the calf, comes down 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. We'll see PTTD in many elderly women. One day they have an arch, the next day they don't.

Treatment of Flatfeet

Treatment of flatfeet really depends upon the symptoms that they may cause. Pain should be the primary motivation for treatment. Obviously we start out with a simple conservative approach in most cases.

The vast majority of children can be treated with arch supports and shoes. This could be an arch support that the shoe repair shop glues into the shoe, it could be a store bought arch support or even a custom made arch support called an orthotic. The key is to try the simple tricks and see if 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 pedorthist. They'll be able to recommend a treatment plan that may be significantly more cost effective for your child in the long run.

Treatment of the adult flatfoot is much the same as we've discussed with children. Try the easy things first such as arch supports 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 flatfoot don't 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, arch supports, orthotics, OTC braces and Rx braces.

At first glance, flatfoot surgery would seem fairly simple; 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. How do we center the weight of the body 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. We also discussed the impact of a tight Achilles tendon in children and its affect on the development of the foot. Quite often I'll lengthen the Achilles tendon in flatfoot repair cases.

Many flatfoot correction procedures involve a wedge resection of the arch or heel. As the wedge is closed, a new arch is formed. Other procedures require fusion of the joint to created needed stability. Many of these cases require prolonged casting to allow for proper healing.

Another type of procedure involves placing a small 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.

The following images show the steps used to perform a STA-Peg procedure. 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 insertion/sizing tools.

Other methods employed in treating flatfeet include a procedure called an Evans Procedure. An Evans Procedure is used to correct abduction of the forefoot. 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 procedures.

The pictures below show the steps used to perform another common flatfoot procedure called 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.

There are a number of specific congenital (from birth) deformities that we see that result in flatfeet. The most common of these conditions 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. The challenge lies in the fact that the symptoms 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.

Tarsal coalitions can form at several different locations in the foot.  The most common coalition forms between the calcaneus and navicular (shown in the x-rays on this page).  The second most common coalition forms in the subtalar joint and is subsequently called a talo-calcaneal coalition.  The third most common coalition forms at the talo-navicular joint.  The etiology of tarsal coalitions is unclear, but most clinicians assume that the coalition forms as the result of an incomplete separation of the developing bones while in utero. 

Treatment of tarsal coalitions

The initial diagnosis of tarsal coalition is based upon clinical findings of a fixed, rigid foot.  Although X-rays don't show any specific location of the early fibrous coalition, they do show early changes in the bone that are secondary to the limited range of motion.  These changes include dorsal spurring of the talo-navicular joint and a halo of increased bone density surrounding the subtalar joint.  This density is one of the radiographic signs of the early onset of osteoarthritis in the subtalar joint.  A definitive diagnosis of a tarsal coalition can be made with an MRI.

Tarsal coalitions can be managed conservatively from the onset of symptoms until the late teens.  Prescription orthotics and bracing can help to relieve a bit of pain but won't help to delay formation of the coalition.  The usual and customary treatment of coalitions is surgical resection of the coalition with or without fusion of the affected joint space.  Generally speaking, calcaneo-navicular (C-N) coalition resections are quite successful.  Resection of a C-N coalition would typically be performed with an interposition of soft tissue or muscle to inhibit regrowth of the coalition.  Talo-calcaneo coalition resections are not quite as successful as an isolated procedure and are often performed in conjunction with a fusion of the joint between the talus and calcaneus (subtalar joint).  The determination of whether fusion is indicated is often dictated by the amount of degenerative change of the subtalar joint seen during the surgery.

At what age should a tarsal coalition be corrected?  From one perspective, the earlier the better is true.  If a tarsal coalition is allowed to remain unaddressed, the foot will become rigid and progressively undergo adaptive change during the second and third decades of the patient's life.  These changes will become fixed and can only be repaired with a salvage fusion procedure called a triple arthrodesis.  But it's also important to allow for skeletal maturity.  Most children reach skeletal maturity between the ages of 16 and 19 years old.  Therefore, the best time for correction of a tarsal coalition is between 16-19 years of age.

The following is a list of common arch conditions. To find more information about these conditions, follow the highlighted link.

Anterior tarsal tunnel syndrome - achy pain on the top of the foot, aggravated by the compression of the shoes.

CT Band Syndrome - the way that the calf delivers load to the arch can significantly affect arch pain.

Cuboid syndrome - the humble cuboid bears significant load and can cause lateral foot pain when overused.

Flatfeet - flatfeet can be due to a number of reasons but can often cause arch pain.

Gout - although more common in the forefoot, gout should be considered in the differential diagnosis of arch pain.

Peroneal tendonitis - sharp pain on the lateral foot at the onset of activity.

Posterior tibial tendonitis - achy pain in the medial arch.

Stress fracture - midtarsal and metatarsal stress fractures are often the cause of nonspecific arch pain.

Tarsal coalition - stiffening of the arch with the onset of symptoms in the early late second decade or early third decade of life.

Tarsal tunnel syndrome - an entrapment of the posterior tibial nerve with pain that radiates into the arch.