All You Ever Wanted to Know about Flat Feet

“Why do my feet turn in?”

“My feet are as flat as pancakes.”

“My child’s feet turn in and they are walking funny, is something wrong?”

“I have pain and swelling along the inside of my ankle and foot.”

These are all common complaints that I hear every single day in my office. The condition is having flat feet, also known as acquired flatfoot deformity which is characterized by the collapse of the medial longitudinal arch of the foot or the bottom and inside portion of the foot. Along with this, it is very common to have a forefoot that points outward and a heel bone that points outward as well. Sometimes this is called the “too many toes sign” (Image 1). There are various causes of this condition but the most common is referred to as posterior tibial tendon dysfunction (PTTD). This has been estimated to affect approximately 5 million people in the United States.

Image 1: “Too many toes sign” and demonstrating heel valgus (heel pointing outwards)

In this condition, the posterior tibial tendon, a tendon 0n the inside of the leg that crosses the ankle and attaches in the foot, weakens or lengthens and can no longer help support and hold the arch up. Many patients are asymptomatic, however, often times, these same patients are concerned with their deformity where as other patients have pain, swelling, worsening deformity, and significant dysfunction and/or difficulty walking or performing activities of daily life.

There are 4 classic stages described in this condition.

Stage I is characterized by mild pain along the inside of the ankle and foot that is exacerbated by activities. There is no deformity and tendon length tends to be normal. X-rays are typically normal as well. Treatment consists of conservative measures including rest, anti-inflammatory medications, physical therapy, arch supports and orthotics. Interestingly, although contrary to popular belief, orthotics do NOT help reverse or delay the progression of the deformity, but instead, help to accommodate the deformity during walking and activities while wearing shoes.

Stage 2 is characterized by moderate pain, swelling along the posterior tibial tendon, which is elongated, and deformity is present and flexible with the classic flattening of the arch with the heel bone pointing outwards and possibly the forefoot pointing outwards as well. Imaging would demonstrate degeneration of the posterior tibial tendon with multiple longitudinal tears. The treatment consists of conservative measure as in Stage I, but if this fails and the patient elects to proceed with surgery, this can be accomplished with deformity correcting surgeries including tendon transfers, ligament repair, and osteotomies (cutting and realigning the positioning of bones).

Stage 3 is characterized by severe pain and a stiff deformity. If conservative measures fail, surgery is recommended consisting of hindfoot fusion procedures.

Stage 4 is characterized by significant pain, a stiff deformity as in Stage 3 but also with ankle joint involvement including pain and deformity of the ankle itself. When conservative measures fail to improve symptoms, surgery is recommended including fusion surgeries of the hindfoot as well as ankle surgery which can include fusion or ankle replacement surgery.

If you or a family member have a painless or painful flatfoot, orthopedic surgeons that are fellowship trained in foot and ankle orthopedic surgery are happy to see you at Ortho Rhode Island. Learn more about our foot and ankle care.