Zeehan S. Husain, DPM
Charles G. Kissel, DPM
Michael S. Schey, DPM
Angela
Stoutenburg, DPM
Board
certified by the
American Board of
Podiatric Surgery.
Flatfoot Deformities
Subtopics
2.
Posterior Tibial Tendon Dysfunction
4.
Orthotics
1.
Flexible
Flatfoot
Flatfoot
is often a complex disorder, with diverse symptoms and varying degrees of
deformity and disability. There
are several types of flatfoot, all of which have one characteristic in
common—partial or total collapse (loss) of the arch. Other characteristics shared by most types of flatfoot
include:
 |
Too
many toes sign— when more than two toes are seen on the side
when looking at the foot from behind the heel |
|
The
heel tilts outwards and the ankle bulges inward |
|
A
tight Achilles tendon, which causes the heel to lift off the ground
earlier when walking and may act as a deforming force |
|
Bunions
and hammertoes may occur in some people with flatfeet |
Health problems such as rheumatoid arthritis or diabetes sometimes increase the risk of developing flatfoot. In addition, adults who are overweight frequently have flatfoot.
Flexible
flatfoot is one of the most common types of flatfoot. It
typically begins in childhood or adolescence and continues into adulthood.
It usually occurs in both
feet and generally progresses in severity throughout the adult years. As the deformity worsens, the soft tissues (tendons and
ligaments) of the arch may stretch or tear and can become inflamed.
The
term “flexible” means that while the foot is flat when standing
(weight-bearing), the arch returns when not standing. In
the early stages of flexible flatfoot arthritis is not restricting motion
of the arch and foot, but in the later stages arthritis may develop to
such a point that the arch and foot become stiff.
Symptoms,
which may occur in some persons with flexible flatfoot, include:
|
Pain
in the heel, arch, ankle, or along the outside of the foot |
|
“Turned-in”
ankle |
|
Pain
associated with shin splints |
|
General
weakness/fatigue in the foot or leg |
Diagnosis
of Flexible Flatfoot
In
diagnosing flatfoot, the podiatric foot and ankle surgeon examines the
foot and observes how it looks when you stand and sit. X-rays
are usually taken to determine the severity of the disorder. If
you are diagnosed with flexible flatfoot but you do not have any symptoms,
your podiatric surgeon will explain what you might expect in the future.
Treatment
Options
If
you experience symptoms with flexible flatfoot, the podiatric surgeon may
recommend various
|
Activity
modifications—
Cut down on activities that bring you pain and avoid prolonged
walking and standing to give your arches a rest. |
|
Weight
loss—
If you are overweight, try to lose weight. Putting too much
weight on your arches may aggravate your symptoms. |
|
Orthotic
devices—
Your podiatric surgeon can provide you with custom orthotic
devices for your shoes to give more support to the arches. |
|
Immobilization—
In some cases, it may be necessary to use a walking cast or to
completely avoid weight-bearing. |
|
Medications—
Non-steroidal anti-inflammatory drugs (NSAID), such as
ibuprofen, help reduce pain and inflammation. |
|
Physical
therapy—
Ultrasound therapy or other physical therapy modalities may be
used to provide temporary relief. |
|
Shoe
modifications—
Wearing shoes that support the arches is important for anyone
who has flatfoot. |
|
Surgery—
In some patients whose pain is not adequately relieved by other
treatments, surgery may be considered. |
Flatfoot
Surgery
A
variety of surgical techniques is available to correct flexible flatfoot. Your case may require one procedure or a combination of
procedures. All of these
surgical techniques are aimed at relieving the symptoms and improving foot
function. Among these
procedures are tendon transfers or tendon lengthening procedures,
realignment of one or more bones, joint fusions, or insertion of implant
devices.
In
selecting the procedure or combination of procedures for your particular
case, the podiatric surgeon will take into consideration the extent of
your deformity based on the x-ray findings, your age, your activity level,
and other factors. The length
of the recovery period will vary, depending on the procedure or procedures
performed.
2. Posterior
Tibial Tendon Dysfunction (top)
Posterior
tibial tendon dysfunction (PTTD) is an inflammation and/or overstretching
of the posterior tibial tendon in the foot.
An important function of the posterior tibial tendon is to help
support the arch. But in PTTD,
the tendon’s ability to perform that job is impaired, often resulting in
a flattening of the foot.
The
posterior tibial tendon is a fibrous cord that extends from a muscle in
the leg. It descends the leg
and runs along the inside of the ankle, down the side of the foot, and
into the arch. This tendon
serves as one of the major supporting structures of the foot and helps the
foot to function while walking. As
the posterior tibial tendon becomes fatigued and overstretched, the tendon
may partially or completely rupture.
PTTD is often called “adult acquired flatfoot” because it is the most common type of flatfoot developed during adulthood. Although this condition typically occurs in only one foot, some people may develop it in both feet. PTTD is usually progressive, which means it will keep getting worse especially if it is not treated early.
Symptoms
of PTTD
The
symptoms of PTTD may include pain, swelling, a flattening of the arch, and
an inward rolling of the ankle. As
the condition progresses, the symptoms will change.
For example:
|
When
PTTD initially develops, typically there is pain on the inside of the
foot and ankle (along the course of the tendon).
In addition, the area may be red, warm, and swollen. |
|
Later,
as the arch begins to flatten, there may still be pain on the inside
of the foot and ankle. But
at this point, the foot and toes begin to turn outward and the ankle
rolls inward. |
|
As
PTTD becomes more advanced, the arch flattens even more and the pain
often shifts to the outside of the foot, below the ankle. The tendon has deteriorated considerably and arthritis often
develops in the foot. In
more severe cases, arthritis may also develop in the ankle. |
What
Causes PTTD?
Overuse
of the posterior tibial tendon is frequently the cause of PTTD. In fact, the symptoms usually occur after activities that
involve the tendon, such as running, walking, hiking, or climbing stairs.
Conservative
Treatments
Because
of the progressive nature of PTTD, it is best to see your foot and ankle
surgeon as soon as possible. If
treated early enough, your symptoms may resolve without the need for
surgery and progression of your condition can be arrested.
In contrast, untreated PTTD could leave you with an extremely flat
foot, painful arthritis in the foot and ankle, and increasing limitations
on walking, running, or other activities.
In many cases of PTTD, treatment can begin with non-surgical
approaches that may include:
|
Orthotic
devices or bracing— To give your arch the support it needs,
your foot and ankle surgeon may provide you with an ankle stirrup
brace or a custom orthotic device that fits into the shoe. |
|
Immobilization—
Sometimes a short-leg cast or boot is worn to immobilize the
foot and allow the tendon to heal, or you may need to completely avoid
all weightbearing for a while. |
|
Physical
therapy— Ultrasound therapy and exercises may help
rehabilitate the tendon and muscle following immobilization. |
|
Medications—
Non-steroidal anti-inflammatory drugs (NSAID), such as
ibuprofen, help reduce the pain and inflammation. |
|
Shoe
modifications— Your
foot and ankle surgeon may advise you on changes to make with your
shoes and may provide special inserts designed to improve arch
support. |
When
Is Surgery Needed?
In
cases of PTTD that have progressed substantially or have failed to improve
with non-surgical treatment, surgery may be required. For
some advanced cases, surgery may be the only option. Surgical treatment may include repairing the tendon,
realigning the bones of the foot, or both. Your
foot and ankle surgeon will determine the best approach for your specific
case.
Flatfoot
is common in both children and adults. When this deformity occurs in children, it is referred to as
“pediatric flatfoot,” a term that actually includes several types of
flatfoot. Although there are
differences between the various forms of flatfoot, they all share one
characteristic— partial or total collapse of the arch.
Most
children with flatfoot have no symptoms, but some children have one or
more symptoms. When symptoms
do occur, they vary according to the type of flatfoot.
Some signs and symptoms may include:
|
Pain,
tenderness, or cramping in the foot, leg, and knee |
|
Outward
tilting of the heel |
|
Awkwardness
or changes in walking |
|
Difficulty
with shoes |
|
Reduced
energy when participating in physical activities |
|
Voluntary
withdrawal from physical activities |
Flatfoot can be apparent at birth or it may not show up until years later, depending on the type of flatfoot. Some forms of flatfoot occur in one foot only, while others may affect both feet.
Types
of Pediatric Flatfoot
Various
terms are used to describe the different types of flatfoot. For example, flatfoot is either asymptomatic (without
symptoms) or symptomatic (with symptoms). As mentioned earlier, the majority of children with flatfoot
have an asymptomatic condition. Symptomatic
flatfoot is further described as being either flexible or rigid.
“Flexible” means that the
foot is flat when standing, but the arch returns when not standing. “Rigid” means the arch is always stiff and flat, whether
standing on the foot or not. Several
types of flatfoot are categorized as rigid. The
most common are:
|
Tarsal
coalition—
This is a congenital (existing at birth) condition. It
involves an abnormal joining of two or more bones in the foot. Tarsal coalition may or may not produce pain. When
pain does occur, it usually starts in pre-adolescence or adolescence
around the ages of 15 to 18 years of age. |
|
Congenital
vertical talus—
Because of the foot’s rigid “rocker bottom” appearance
that occurs with congenital vertical talus, this condition is apparent
in the newborn. Symptoms
begin at walking age, since it is difficult for the child to bear
weight and wear shoes. |
|
Other—
Can be caused by injury or congenital disease |
Diagnosis
In
diagnosing flatfoot, the foot and ankle surgeon examines the foot and
observes how it looks when the child stands and sits. The
surgeon also observes how the child walks and evaluates the range of
motion of the foot. Because
flatfoot is sometimes related to problems in the leg, the surgeon may also
examine the knee and hip. X-rays
are often taken to determine the severity of the deformity.
Sometimes an MRI study, CT scan, and blood tests are ordered.
Conservative
Treatments
If
a child’s flatfoot is asymptomatic, treatment is often not required.
Instead, the condition will be observed and re-evaluated
periodically by the foot and ankle surgeon.
Custom orthotic devices may be considered for some cases of
asymptomatic flatfoot.
In
symptomatic pediatric flatfoot, treatment is required. The
foot and ankle surgeon may select one or more approaches, depending on the
child’s particular case. Some
examples of non-surgical options include:
|
Activity
modifications—
The child needs to temporarily decrease activities that bring
pain as well as avoid prolonged walking or standing. |
|
Orthotic
devices—
The foot and ankle surgeon can provide custom orthotic devices
that fit inside the shoe to support the structure of the foot and
improve function. |
|
Physical
therapy—
Stretching exercises, supervised by the foot and ankle surgeon
or a physical therapist, provide relief in some cases of flatfoot. |
|
Medications—
Non-steroidal anti-inflammatory drugs (NSAID), such as
ibuprofen, may be recommended to help reduce pain and inflammation. |
|
Shoe
modifications—
The foot and ankle surgeon will advise you on footwear
characteristics that are important for the child with flatfoot. |
When
Is Surgery Needed?
In
some cases, surgery is necessary to relieve the symptoms and improve foot
function. The podiatric
surgeons at the Rochester Center for Foot and Ankle Surgery perform a
variety of techniques to treat the different types of pediatric flatfoot. The
surgical procedure or combination of procedures selected for your child
will depend on his or her particular type of flatfoot and degree of
deformity.
If your heel swings too far when you walk, your foot may be flattening too much. This incorrect movement stresses and weakens parts of your foot. Over time, you may develop symptoms in your feet, ranging from a change in shape to pain when you walk. The foot alignment affects the ankle, knee, and hip joints as well as the low back. If a medical problem places your feet at risk, you need help protecting these tender areas.
Supportive
Orthotics
Orthotics control movement and stop strain. They limit the amount your foot flattens. The stress of weightbearing is better distributed throughout your foot, reducing strain on soft tissue and joints. Existing bone or soft tissue changes may not disappear, but orthotics can help reduce or eliminate your foot pain. If your hips or knees also hurt, orthotics may relieve this symptom, also.
What
is Best for You?
Orthotics come in a variety of materials, ranging from rigid plastic to soft foam. All of these materials can be shaped to fit your individual foot. The rigid orthotics offer the most control of movement, while the softer ones provide better cushioning and protection. When prescribing your orthotics, your podiatrist makes the best match between your needs and the qualities of the materials.
Custom
Orthotics
To meet your unique needs, your orthotics will be custom-built from cast impressions of your feet as it is held in a corrected position. Afterward, you will try out the orthotics to make sure they fit correctly. During this fitting, your podiatrist may instruct you about breaking them in. You may also discuss proper shoe selection.
Follow-Up
Visits
Regular podiatric checkups can help you maintain the health of your feet. As with contact lenses, your orthotics prescription may change over time, and your podiatrist may recommend new orthotics. Children, athletes, and people with health concerns affecting their feet may require special care. Your podiatrist will recommend a follow-up schedule to meet your individual needs.
