FLAT FOOTDR MANOJ R. KANDOIM.S., D’ORTH,FCPS,DNB,FICS(CHICAGO),FIHS(ITALY),FIFAS(GERMANY)Flat feet (also called pes planus or fallen arches) is a formal reference to a medical condition inwhich the arch of the foot collapses, with the entire sole of the foot coming into complete ornear-complete contact with the ground. In some individuals (an estimated 20–30% of the generalpopulation) the arch simply never develops in one foot (unilaterally) or both feet (bilaterally).One of the more common signs of flatfoot is the "too many toes" sign. Even the big toe can be seen from the back of this patients foot. In a normal foot, only the fourth and fifth toes should be visible.SymptomsDepending on the cause of the flatfoot, a patient may experience one or more of the differentsymptoms below: Pain along the course of the posterior tibial tendon which lies on the inside of the foot and ankle. This can be associated with swelling on the inside of the ankle. Pain that is worse with activity. High intensity or impact activities, such as running, can be very difficult. Some patients can have difficulty walking or even standing for long periods of time. When the foot collapses, the heel bone may shift position and put pressure on the outside ankle bone (fibula). This can cause pain on the outside of the ankle. Arthritis in the heel also causes this same type of pain. Patients with an old injury or arthritis in the middle of the foot can have painful, bony bumps on the top and inside of the foot. These make shoewear very difficult. Occasionally, the bony spurs are so large that they pinch the nerves which can result in numbness and tingling on the top of the foot and into the toes. Diabetics may only notice swelling or a large bump on the bottom of the foot. Because their sensation is affected, people with diabetes may not have any pain. The large bump can cause skin problems and an ulcer (a sore that does not heal) may develop if proper diabetic shoewear is not used.
TYPES:There are two types of flatfoot, one that people are born with that is usually seen as atoddler or adolescent years and the other is an aquired adult flatfoot that becomesnoticable usually in the fourth or fifth decade of a persons life. We will address theseseparately since treatments are somewhat different in both types of cases.THE INFANT FLATFOOT IS GENERALLY NORMAL!Infants have a foot that usually appears to be flat, this is due to an increase in the amountof fat in the foot and its distribution. Also the foot has not yet dealt with the forces ofgravity and has not aquired an arch to support the body weight. The foot of an infant doesnot indicate the future of the formation of an arch. There are some congenital deformitiesthat may show up as a severe flatfoot in that age group but they are very very rare.THE PEDIATRIC FLATFOOT-This is probably the most common kind of flatfoot and most times it is a concern for theparents or guardians and not necessarily the child. The flatfoot can be divided into twokinds, the flexible flatfoot and the rigid flatfoot. The flexible flatfoot has an arch that maybe present when the child is not putting any weight on the foot but disappears when weightis applied. The arch can reappear when a child stands on their tiptoes, this is due to aphenomenon called the windlass mechanism where the structures of a foot work together torecreate the arch.A fallen arch generally will not lead to disability and problems in the future but the phrase"the child will grow out of it " is not exactly true in most cases. A severe flatfoot at an earlyage can cause joint pain and arthritis if not addressed, then again, maybee not. Noone candefinatly say surgery or any treatment is absolutely necessary without a thoroughexamination and xray evaluation. ( xrays always need to be done with the patient stadingwith their weight on the feet.)An examination will provide enough details to then be able to discuss further treatment. Itis a well know fact that foot orthotics do help decrease pain by supporting the arch but donot reform an arch and must be worn consistantly to help at all.A flexible flatfoot that is asymptomatic is generally treated with orthotics, ones that causepain and a change in activities of daily living are occasionaly addressed with surgery.
There are a number of procedures, bone cuts ( osteotomy) , joint fusions ( removal ofjoints), and soft tissue procedures such as tendon transfers, tendon lenghtenings andligament tightenings. These are chosen based on the plane of deformity or the position ofthe flatfoot bone segments.There is also a common procedure called the arthroeresis where a small titanium implant isplaced just outside the subtalar joint in a child between the ages of 5 and 12 approximatly.This implant prevents the excessive motion of this joint in the back of the foot that allowsthe foot to pronate or fall into this flatfoot position. This implant allows the developingjoint to reform itself into one with less range of motion and prevents the arch fromflattening. The implant has also been successful in treating older patinets as well withflatfoot condition.THE ADULT ACQUIRED FLATFOOT-This condition is also commonly known as posterior tibial tendon dysfunction. Thiscondition is most common in women over 40 years of age but can happen to anyone, Theligaments and muscles around the rear of the foot begin to weaken and this allows the archto collapse over time. The posterior tibial tendon helps hold the arch up and may tearovertime leaving the arch to fall as well. This is usually first treated conservatively but insevere cases surgical treatment is warranted. depending on the condition of the joints andtheir level of arthritic changes. There are those patients that present with arthritic changes in their foot joints from a longstanding flatfoot deformity ( common in PTTD, adult aquired flatfoot). In these cases jointsparing bone cuts called osteotomy to realign the foot generally do not work and a moreaggressive fusion surgery is necessary. This includess removing the arthritic painful joints
completely and letting the bones heal together. The patient will experience some loss ofmotion in the small joints of the foot but this is rarely noticable since other joints in the footand ankle compensate for this. Also the patient usualy already has very little motion injoints that are affected by degenerative arthritis.There is one more form- one that needs to be addressed properly the :THE PERONEAL SPASTIC FLATFOOT-This is a condition where there is an irritant in one of the joints in the back of the foot. Thebody tries to limit motion of that irritated joint by putting muscles in spasm near thosejoints. Unfortunatly this causes a sometimes painful foot deformity where the foot starts todrift out to the outside. This occurs most often in teens ages 11-15, in both girls and boys, inboth feet or in one foot.Posterior Tibial Tendon Dysfunction (PTTD)Treatment Options:If you experience symptoms with flexible flatfoot,surgeon may recommend varioustreatment options, including:• Activity modifications. Cut down on activities that bring you painand avoid prolonged walking and standing to give your arches a rest.• Weight loss. If you are overweight, try to lose weight. Putting toomuch weight on your arches may aggravate your symptoms.. Surgery:A common cause of flat feet in an adult is a partially or completely ruptured posterior tibial tendon.The ruptured tendon is supported with another tendon and the heel bone can be repositioned.
These procedures help support the arch by restoring normal function to the torn tendon and heel.In older children and adults, the tendon that supports the arch (posterior tibial tendon) is often partially or completely torn.This causes continued flattening of the arch and tilting of the heel bone. If conservative care is not successful,the ruptured tendon is supported with another tendon, and the heel bone can be repositioned.This procedure helps support the arch, by restoring normal function to the torn tendon and heel.Sometimes a tight heel cord adds to the excessive pressure on the foot and causes it to flatten.Lengthening it helps relieve this pressure and restores the arch to its normal height.In older children and adults surgery also involves supporting the structures of the inside of the foot.A wedge of bone is removed from the middle of the arch area that sags and a new, normal arch is createdA proper evaluation of the causes of a flat foot determines the best surgical course needed to correct the deformity.A bone wedge procedure or tendon lengthening in combination with other procedures extends the recovery time,but benefits the patient for a lifetime.Conclusion on Flat Feet PainUnfortunately many people think little can be done to correct flat feet. This misconception is from a lack ofeducation and understanding about this often overlooked problem. Selected surgical procedures can correctthis common condition.