Flatfoot

What is it?

Understanding of adult flatfoot deformity and its treatment has progressed dramatically over the last decade but there are still many unanswered questions as to what causes it and how we can stop it from getting worse. The main problem that you face is the progressive flattening of the arch on the inside of your foot with pain over the inside of the ankle. As the condition worsens you might start to get pain on the outside of the foot from the abnormal biomechanics of the flattened foot.

Why does it happen?

​​The most common reason for painful flatfoot is the overload of the tendon on the inside of the ankle. People who suffer from this pain usually have always had a flatfoot but over time due to the abnormal position of the foot, the tendon becomes overloaded and painful. It is more common in people of afro-Caribbean descent and in Caucasian ladies over 40 but can affect any race and age group. Other things I look out for are when the flatfoot is very stiff, it may be caused by the bones at the back of the foot being joined together from birth or an extra bone at the inside of the ankle which can be inflamed. In older people, flatfoot may be caused by arthritis of the bones in the middle of the foot and this needs a different treatment plan to tendon problems.

How can I treat it?

Depending on your symptoms, I always like to try non-surgical treatments to get over flatfoot pain before considering surgery. If the tendon is acutely painful a period of rest in a special boot or strapping with Kinesio tape can help. Once the pain is more under control physiotherapy to stretch the Achilles tendon and strengthen the overloaded posterior tibial tendon on the inside of the ankle can improve symptoms and stop the problem from coming back. In conjunction with this, I arrange for insoles to protect your foot and take the pressure off the tendons on the inside which can work very well to stop the symptoms from coming back.

What does surgery involve?

Classically, surgery involved a large incision on the inside of the foot and the removal of the damaged tendon. A different tendon was then taken from under the foot and sewn onto the bone to recreate its function. This reduced the pain but had quite a high failure rate. To offload the repair since the early 90s, surgeons routinely also make a cut on the outside of the foot breaking the heel bone and moving it inwards to protect the reconstruction. This gives reliable results but does not greatly improve foot position, has a long recovery, and entails the lifelong need for insoles.

I now take a pragmatic approach to a flatfoot deformity and utilise a number of modern procedures to give, what I believe is a better result with less trauma and therefore a quicker recovery.

For early flatfoot without too much deformity in the heel, if the tendon is still painful after a period of offloading, I utilise what is called an “arthrodesis” screw which is a minimally invasive procedure to stop the foot from flattening out and works as an internal orthotic.​

This is the basis of my treatment of flatfoot deformity. When I visited one of the world’s most eminent foot and ankle surgeons in Paris, he routinely uses this procedure alone to treat flatfoot but I usually prefer to do keyhole camera surgery of the tendon to rule out any little tears and to reduce inflammation. I also carefully assess for Achilles tightness and do a mini-open release of the muscle which dramatically helps offload the foot if the Achilles is tight.

If there is significant flattening of the heel bone, I cut the heel bone percutaneously using a minimally invasive burr and fix it with 2 percutaneous screws.

Only if the tendon is significantly damaged do I do an open tendon reconstruction but using modern fixation implants and internally bracing the ligament on the inside, I can do this through a much less invasive incision than classic surgery.

In some cases where the flatfoot has been present for many years and the foot is stiff and arthritic, a hindfoot fusion is needed to alleviate symptoms. I do this through a single incision on the inside of the ankle and although there is a prolonged recovery, there are usually significant benefits when it comes to pain and foot position.

Aftercare

Recovery is relatively quick after arthroeresis, tendon camera surgery, and mini open muscle release. You will be in a boot and bandage for 2 weeks followed by appropriate insoles which I recommend you use for up to a year and back to gentle jogging at around 8 weeks.

If the heel bone needs to be cut you will be in a non-weightbearing case for 2 weeks, followed by a boot for 4 weeks and full recovery at 3-4 months.

If a tendon reconstruction is required the treatment is the same as with a heel bone cut but full recovery can take up to a year. This is the same for a fusion procedure. If the disease is significant enough to warrant these procedures, I usually recommend that you wear your orthotics when wearing shoes long-term to stop the problem from reoccurring.

Risks and complications

​There are risks to all surgery and conservative measures should be tried when possible. If surgery is an option, we will discuss all of the pros and cons and the risks that are specific to you in detail.

There is a risk of ongoing pain and swelling which can take some time to settle down, especially with more involved surgery. All patients heal differently and I will monitor your progress after surgery until you reach a full recovery. The arthroeresis screw can cause pain and in around 20% of cases has to be removed. This is simple day-case surgery with only minimal recovery but I do not like to do this for at least a year after surgery to ensure that the correction is maintained.