Flatfoot in Clinical Practice: Diagnosis, Treatment, and Long-Term Care

Flatfoot: Diagnosis and Management – A Comprehensive Guide for Medical Professionals

Flatfoot, also known as pes planus or fallen arches, is a condition where the foot loses its normal arch and flattens against the ground. It can affect both children and adults, and in some cases, it may cause pain and functional limitations. While many people with flatfoot do not experience symptoms, others may suffer from discomfort, fatigue, and other musculoskeletal issues.

Flatfoot can be congenital or acquired later in life due to factors such as obesity, injury, or degenerative changes in the foot’s supporting structures. Understanding the different types of flatfoot, risk factors, diagnostic criteria, and management options is essential for healthcare providers. Early diagnosis and treatment can help prevent complications and improve patient outcomes, making this condition an important topic for medical professionals.

This article provides a detailed exploration of the causes, diagnosis, and management of flatfoot, tailored to medical students and doctors. We will cover both non-surgical and surgical management options, with a focus on evidence-based practices.

Anatomy of the Foot and the Arch

The foot is a complex structure made up of bones, muscles, tendons, and ligaments that work together to support the body’s weight, absorb shock, and provide mobility. A normal foot has three arches:

• Medial longitudinal arch: This is the most prominent arch, running along the inner side of the foot from the heel to the forefoot.
• Lateral longitudinal arch: This arch is on the outer side of the foot, providing stability.
• Transverse arch: This arch runs across the midfoot and contributes to the foot’s ability to adapt to uneven surfaces.

The posterior tibial tendon and other ligaments are responsible for maintaining the integrity of the medial longitudinal arch. When these structures weaken or fail, the arch collapses, resulting in flatfoot.

Types of Flatfoot

Flatfoot can be categorized into different types based on etiology, onset, and presentation.

1. Congenital Flatfoot
Congenital flatfoot, or flexible flatfoot, is present from birth. This condition is common in infants and young children, and in most cases, it resolves as the child grows. The arch may appear to be absent when standing but forms when the foot is off the ground. This is known as a flexible flatfoot because the arch is present when non-weight-bearing.

2. Acquired Flatfoot
Acquired flatfoot typically develops in adulthood, and it may be rigid or flexible. This type of flatfoot is more likely to cause symptoms, including pain and difficulty walking. The most common form of acquired flatfoot is adult-acquired flatfoot deformity (AAFD), which occurs due to the dysfunction of the posterior tibial tendon.

3. Rigid Flatfoot
In contrast to flexible flatfoot, rigid flatfoot is a more severe condition in which the foot remains flat even when non-weight-bearing. This type of flatfoot can result from congenital conditions such as tarsal coalition, a condition where two or more bones in the foot fuse together, limiting movement.

Causes and Risk Factors of Flatfoot

Flatfoot can arise from a variety of causes, and certain factors increase the risk of developing this condition.

1. Genetic Predisposition
A family history of flatfoot can increase the likelihood of developing the condition, particularly in congenital flatfoot. Certain foot shapes, such as low arches, can be inherited, making individuals more susceptible to flatfoot.

2. Posterior Tibial Tendon Dysfunction (PTTD)
The posterior tibial tendon plays a critical role in maintaining the medial longitudinal arch. Overuse or injury to this tendon can lead to posterior tibial tendon dysfunction (PTTD), resulting in a progressive collapse of the arch and the development of adult-acquired flatfoot.

3. Obesity
Excess body weight places additional stress on the feet, which can contribute to the weakening of the supporting structures and the development of flatfoot.

4. Age
As people age, the tendons and ligaments in the foot may weaken, leading to acquired flatfoot. Degenerative changes in the foot, such as arthritis, can also contribute to the collapse of the arch.

5. Injury
Trauma to the foot, particularly fractures or ligament tears, can disrupt the normal structure of the foot and lead to flatfoot.

6. Other Medical Conditions
Conditions such as diabetes, rheumatoid arthritis, and neuromuscular disorders (e.g., cerebral palsy, Charcot-Marie-Tooth disease) are associated with a higher risk of developing flatfoot. These conditions can affect the integrity of the foot’s ligaments, tendons, and muscles.

Symptoms of Flatfoot

Not all individuals with flatfoot experience symptoms. In fact, many people with flexible flatfoot have no pain or limitations in function. However, in cases where symptoms occur, they can vary in severity and may include:

1. Foot and Ankle Pain

• Location: Pain is typically felt along the inside of the foot and ankle, where the arch has collapsed. In cases of posterior tibial tendon dysfunction, pain may radiate along the course of the tendon.
• Aggravating factors: Pain may worsen with prolonged standing, walking, or physical activities, particularly those involving weight-bearing on uneven surfaces.

2. Swelling

Swelling may occur along the inside of the ankle, especially in cases of tendon dysfunction or inflammation.

3. Difficulty Walking

Individuals with flatfoot may experience difficulty walking due to pain, fatigue, or altered gait mechanics. They may also develop overpronation, where the foot rolls inward excessively during walking or running.

4. Shoe Wear

Excessive wear on the inside of shoes is a common sign of flatfoot, as the collapsed arch leads to increased pressure on the inner edge of the foot.

5. Secondary Issues

Flatfoot can lead to secondary musculoskeletal problems, such as knee, hip, or lower back pain, due to the altered alignment of the lower extremities and compensatory changes in gait.

Diagnosis of Flatfoot

The diagnosis of flatfoot involves a combination of clinical history, physical examination, and imaging studies. It is essential to differentiate between flexible and rigid flatfoot, as this will guide management decisions.

1. Clinical History

The patient’s history should focus on the onset of symptoms, any history of trauma, and the presence of any systemic conditions that may contribute to flatfoot. Questions should also be asked about activity levels, shoe wear patterns, and any family history of foot deformities.

2. Physical Examination

a) Inspection

During the physical exam, the clinician should inspect the foot while the patient is standing and walking. A flattened medial arch, excessive pronation, and forefoot abduction may be observed. Additionally, the clinician should check for signs of swelling or inflammation around the ankle.

b) Range of Motion

Passive and active range of motion of the foot and ankle should be assessed. In flexible flatfoot, the arch may reappear when the patient is non-weight-bearing or when the toes are passively dorsiflexed. In rigid flatfoot, the arch remains flat regardless of the position of the foot.

c) Single-Leg Heel Raise Test

This test is used to assess posterior tibial tendon function. The patient is asked to stand on one foot and raise the heel off the ground. In normal feet, the arch should elevate, and the heel should tilt inward. In cases of posterior tibial tendon dysfunction, the arch will remain flat, and the heel will not tilt inward.

3. Imaging Studies

a) X-rays

X-rays are useful for evaluating the bony structure of the foot and identifying any structural abnormalities, such as tarsal coalition or arthritis. In cases of adult-acquired flatfoot, X-rays can show the severity of the deformity and any associated joint changes.

b) Ultrasound

Ultrasound can be used to assess the condition of the posterior tibial tendon and detect any signs of inflammation or tears.

c) Magnetic Resonance Imaging (MRI)

MRI is indicated in cases where posterior tibial tendon dysfunction is suspected or when the diagnosis is unclear. It provides detailed images of the soft tissues and can help assess the extent of tendon damage.

Management of Flatfoot

The treatment of flatfoot depends on the type, severity, and presence of symptoms. In asymptomatic cases, no treatment may be necessary. However, symptomatic flatfoot, particularly adult-acquired flatfoot, often requires intervention to alleviate pain and prevent progression.

1. Conservative (Non-Surgical) Management

a) Orthotics and Supportive Footwear

Custom orthotics, such as arch supports or insoles, can help redistribute pressure on the foot and provide support to the collapsed arch. Supportive footwear with a stiff sole and adequate arch support can also help reduce symptoms.

b) Physical Therapy

Physical therapy plays a crucial role in managing flatfoot, particularly in cases involving posterior tibial tendon dysfunction. A physical therapist can guide patients through exercises aimed at:

• Strengthening the intrinsic foot muscles: Exercises to strengthen the foot’s arch muscles and improve overall foot stability.
• Stretching the Achilles tendon: Tightness of the Achilles tendon is common in flatfoot, and stretching exercises can help improve flexibility and reduce strain on the foot.
• Improving balance and proprioception: Exercises to improve balance can prevent falls and further injury.

c) Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs, such as ibuprofen or naproxen, can help reduce inflammation and relieve pain in cases of flatfoot associated with tendonitis or arthritis.

d) Activity Modification

Patients may need to modify their activities to avoid exacerbating symptoms. This may include reducing prolonged standing, avoiding high-impact sports, or alternating between different types of physical activity to prevent overuse.

2. Advanced Non-Surgical Treatments

a) Bracing

In cases of significant posterior tibial tendon dysfunction, ankle-foot orthoses (AFOs) may be prescribed to support the foot and ankle, prevent further collapse, and reduce pain. These braces are typically worn during weight-bearing activities.

b) Corticosteroid Injections

In cases of persistent pain and inflammation, corticosteroid injections may be considered. However, repeated injections are generally avoided due to the risk of tendon weakening.

3. Surgical Management

Surgical intervention is considered when conservative treatments fail, and the flatfoot deformity causes significant pain or disability. The specific procedure chosen depends on the underlying cause and severity of the flatfoot.

a) Tendon Repair or Reconstruction

In cases of posterior tibial tendon dysfunction, the damaged tendon may be repaired or reconstructed using a tendon transfer. Flexor digitorum longus tendon transfer is a common procedure in which a tendon from the lower leg is used to replace the dysfunctional posterior tibial tendon.

b) Osteotomy

An osteotomy involves cutting and realigning the bones of the foot to correct the deformity. This procedure is often performed in conjunction with tendon reconstruction to improve foot function.

c) Arthrodesis (Fusion)

In severe cases of flatfoot, where the foot joints have become arthritic, fusion surgery (arthrodesis) may be necessary. This involves fusing the bones of the foot and ankle to create a more stable and pain-free foot, but it limits flexibility.

d) Lateral Column Lengthening

This procedure involves inserting a bone graft into the lateral aspect of the foot to correct the collapse and restore the arch. It is often used in conjunction with tendon reconstruction.

Long-Term Management and Prognosis

The prognosis for flatfoot depends on the severity of the condition and the effectiveness of the treatment. With early intervention and appropriate management, many individuals with flatfoot can achieve symptom relief and avoid long-term complications.

Patients who undergo surgical treatment for flatfoot may require a period of rehabilitation, including physical therapy, to restore strength, range of motion, and function. Long-term follow-up is necessary to monitor for recurrence of symptoms or complications.

Conclusion

Flatfoot is a common condition that can range from asymptomatic to severely disabling. Early diagnosis and appropriate management are essential for preventing complications and improving patient outcomes. Treatment options vary depending on the type and severity of flatfoot and may include conservative measures such as orthotics, physical therapy, and activity modification, as well as surgical interventions in more severe cases.

By understanding the anatomy, pathophysiology, and available treatments for flatfoot, medical professionals can provide individualized care that addresses both the functional and symptomatic aspects of this condition.