What Is A Flat Foot?
A flat foot is a term used to described a collapsed arch. Medically, the term is pes planovalgus (for foot flatten and pushed outwards). There are varying degrees of ‘flatness’. Though not all flat feet are problematic, however, when there are painful flat feet can cause significant discomfort and activity limitations.
There are two kinds of flat feet – flexible (mobile) or rigid (stiff). A flexible flat foot is one where the foot retains motion, and the arch is able to be recreated when there is no weight on the foot. In contrast, a rigid flat foot is ‘stuck’ in the flat position regardless of whether or not there is pressure placed on the foot.
What Are The Symptoms Of Flat Feet?
Flat feet can exhibit a variety of symptoms – from mild to severe. The extent of the flat foto does not always correlate with the extent of symptoms. Patients may complain of arch pain and heel pain. Commonly there is pain on the outside of the foot – where the foot meets the ankle as the collapse foot abuts against the ankle. Muscle cramps within the foot, and onto the leg (shin splints) may occur.
In general, patients have pain with activity – such as walking or running. The pain may be deep and focal to a generalized widespread achy feeling. Irritation from shoe gear can cause redness and swelling.
Causes of Flat Feet
There are a variety of causes of flat feet. Flat feet can be genetic, acquired and develop over time. Young children and teens can have no arches. Injury can lead to flat feet. Tendon problems, and arthritis can lead to flat feet. Rigid flat feet may occur from a condition called tarsal coalition, where the bones in the back of the foot are genetically fused or locked together. For more of tarsal coalition – click here.
When to Seek Treatment
Common reasons patients seek treatment are: pain, interference with walking or activities, difficulty fitting shoes, swelling, and/or notice a change in appearance of the foot and/or unsightly appearance.
Depending on your overall health, symptoms and severity of the the flat foot, the condition may be treated conservatively and/or with surgery.
Non-operative Treatments For Flat Feet
Non-surgical treatments for flat feet are centered at decreasing and/or resolving the symptoms (pain).
Simple Treatments Patients Can Do:
● Wear proper supportive shoes
● Use an arch support
● Wear shoes with a wide toe box
● Modify your activities
● Lose weight
● Wear shoes with cushion
Non-surgical treatments Dr. Blitz can add:
● Prescribe an oral anti-inflammatory medication
Anti-inflammatory medication is useful to significantly reduce pain and inflammation.
● Prescribe physical therapy
A physical therapist may perform ultrasound and other techniques to reduce inflammation. You will also be instructed how to stretch your foot and leg properly. Keeping the joint mobile may preserve function. Strengthening weak foot and leg musculature can help prevent further collapse.
● Prescribe protective pads
Padding and/or cushioning of when areas of bone become prominent on the bottom of the foot, as an effective method of preventing mechanical irritation with shoes. Pads with cutouts may off-weight specific areas of concern.
● Prescribe custom foot orthotics
A custom foot orthotic is a doctor prescribed arch support that is made directly from a casting (mold) of your feet, and theoretically should provide superior support compared to shoe insert that you would purchase from a pharmacy. In the case of flat feet, specific modifications can be made to the orthotic device to strategically balance the foot.
● Prescribe custom ankle-foot orthoses
A custom ankle-foot orthotic (AFO) is a doctor prescribed molded arch and lower leg support that stabilizes both the foot and ankle. This is used when the flat foot is significant and provides more support than the simple foot only insert.
● Give cortisone injection
A articular cortisone injection is a powerful anti-inflammatory medication that is used to rapidly reduce the pain associated with inflammation. Cortisone shots can be extremely effective in alleviating symptoms of flat feet, but will not correct the structure.
Flat Foot Surgery (Foot Lift)
Surgery for flat feet is separated into three kinds: soft tissue procedures, bone cuts, and bone fusions. Depending on the severity of the flat foot, a person’s age, and whether or not the foot is stiff determines just how the foot can be fixed. In most cases a combination of procedures are performed.
With flexible flat feet, surgery is geared at maintaining the motion of the foot and recreating the arch. Commonly this may involve tendon repairs along the inside of the foot to reinforce the main tendon that lifts the arch. When the bone collapse is significant, bone procedures are included to physically rebuild the arch, and realign the heel. The presence of bunions with flat feet is often contributing to the collapse and in most situations requires correction.
With rigid flat feet, surgery is focused on restoring the shape of the foot through procedures that eliminate motion. In this case, motion does not exist pre-operatively, so realigning the foot is of utmost importance. The exception, are rigid flat feet due to tarsal coalition (fused segment of bone) in the back of the foot where freeing the blockage can restore function.
Tendon Transfers & Augmentations (Kidner Procedure)
With flat feet, there is a tendon on the inside of the foot than can often become weakened, injured, split and/or ruptured. This tendon, is called the posterior tibial tendon, and is the main arch supporting tendon. Obviously damage to this tendon can cause collapse of the arch. Some people have genetically inefficient tendon, and tends to be the case in younger people. In mild cases, such as tendon splits, the posterior tibial tendon can be repaired to restore its strength. Acute incontinuity of the tendon can be primarily repaired. Often the posterior tibial tendon is augmented with a tendon transfer of an adjacent tendon to provide both strength and continuity. In any tendon repair, advanced or retensioning of the tendon is performed. In most flat foot surgery a tendon augmentation is often combined with other boney procedures to restore structure and balance to the foot.
Joint Spacers (Artheroesis Procedures)
A procedure that involves placing a metallic implant (most commonly) at the junction where the foot meets the ankle. This device causes the physical blockade that prevent the collapse. It is a procedure that is only indicated for mobile feet, and should not be used with rigid flat feet. Dr. Blitz finds this procedure better for younger patients with flexible flat feet where the bone alignment is still developing so that the foot can adapt to function in a better aligned position.
There are two types of bone procedure for flat feet, those where bone cuts and bone grafts are used to alter the alignment by avoiding any joint structures, or joint invasive procedures (called fusions or arthrodeses) that remove a joint to reshape the foot. With joint fusion procedures, there are those procedures that involve non-essential joints of the foot versus those that involve essential joints.
All bone procedures have their place in flat foot surgery, and Dr. Blitz carefully evaluates each foot to preserve as much motion and function while obtaining proper and adequate alignment.
In many cases a flat foot reconstruction involves both soft tissue procedures and bone procedures to rebuild and restore the arch.
● Arch Fusion (Lapidus Arthrodesis and/or Navicuocuneiform arthrodesis)
There are several joints in the arch of the foot that can collapse – and these joints are non-essential joints of the foot. This does not mean that they do not have a purpose, but rather become inefficient is providing a stable platform for function. As such, locking these non-essential non-functioning joints into place is commonly recommended. These joints are fused together with screws and/or plates.
● Heel Bone Realignment (Calcaneal Osteotomy)
A heel bone that is no longer in proper position and pushed outwards away from the foot can be corrected with a bone cut and realignment procedure, so long as the displacement is not too significant. A benefit of this surgery is that it keeps the back portion of the foot mobile, and helps the surrounding tendons work for efficiently in maintaining the arch.
● Outside Foot Expansion (Evans Calcaneal Osteotomy)
In certain flat feet, the foot is deviated outwards and away from the midline of the body. Sometimes, this is due to the outer portion of the foot being shorter than the inner portion. Here bone graft can be added to the outer edge of the foot to lengthen the foot to swing the foot over into a corrected position.
● Cotton Osteotomy
This procedure is most commonly performed in children and young adults. A bone graft is inserted into the top part of the arch to realign a component of the flat foot, medically known as forefoot varus or medial column elevatus.
● Rearfoot Fusions
The back part of the foot (called the rearfoot complex) can be the cause (or source) of the flat foot or the simply affected by the flat foot foot. In simple terms, the back part of the foot can be made to flatten out due to arch problems – and vica versa for that matter. Dr. Blitz specifically identifies the cause of the flat foot as this will determine the best treatment plan, as each flat foot needs to be evaluated individually.
The rearfoot is made up of three joints, and depending on the extent and most importantly the rigidity of these joints, they may require fusion to restore alignment. When all three joints require fusion – this call is a triple arthrodesis. For completeness, isolated fusion of any of the three joints can be performed (such as subtalar joint arthrodesis, talonavicular arthrodesis, and calcaneaocuboid joint arthrodesis). The medical decision making for isolated fusions is beyond the scope this article, but Dr. Blitz tries to avoid any rearfoot fusion for flexible feet because these are joints are essential joints of the foot, especially in younger people. Those in severe cases, it may be advantageous to provide re-alignment.
What Anesthesia Is Needed For A Foot Lift
Flat foot surgery is performed as both outpatient surgery or inpatient surgery depending on the extent of the work needed. More often the surgery is performed under a regional, spinal or general anesthetic.
What Are The Risks Of Flat Foot Surgery
Any surgery has general risks, and flat foot surgery is no exception. Ofcourse there are anesthetic risks. Complications may occur with any surgery and are not necessarily your fault, or the fault of your surgeon. Nonetheless, you should understand the risks.
Flat foot surgery complications include, but are not limited to: infection, pain (temporary or permanent), swelling, hematoma, bleeding, blood clot, poor wound healing, incision breakdown, poor bone healing (delayed union, nonunion), malunion, nerve injury, disability, recurrence, hallux varus, metatarsalgia, unsightly scar, stiffness, shortness of toe, weakness, hardware problems, need for revisional surgery, and/or catastrophic loss.