Bilateral flatfoot before Surgery and  Bilateral flatfoot after Surgery
Ankle Arthroscopy and Subtalar Arthroscopy
Ankle Arthritis in Rhuematoid patient and Ankle Replacement in Rhuematoid Arthritis
Diabetic foot before Surgery and Diabetic foot after Surgery
Claw toe deformity in Rhuematoid patient and Claw toe deformity in Rhuematoid patient after surgery
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Foot Pain in India/Flat Foot in India


A flat foot is a Orthopaedic condition of the foot where foot looses its normal arch. The arch, or instep, is the inside part of the foot that is usually raised off the ground when you stand, while the rest of the foot remains flat on the ground. Most people have a noticeable space on the inner part of their foot (the arch). The height of the arch varies from person to person.

As the condition worsens it gives rise to pain and discomfort during normal walking. As arch collapses further it leads to curling out of the heel. It can also give rise to leg pain, ankle pain, heel pain and pain in the knees, hips and back.

 

 
Normal Foot
Flat Foot
Flatfoot leading to deformity of Heel
   
 
Picture showing a normal foot on the left and a flat foot next to it. Note that as the foot arches collapse the heel curls out to accommodate new position of foot.
 

 

Is a flat foot always a bad thing?

No, not all flat feet are bad. Flat feet are mainly of two types:-

1.
Congenital or those which are present since birth. These can be flexible or stiff. It is important to differentiate whether it is flexible or stiff.
 
 
The arch of a flexible flat foot can be reconstituted by extending the big toe or standing on tip toe It is rarely symptomatic and compatible with all the activities of daily living. Flexible flat feet are usually bilateral. In such cases reassurance is usually all that is required. 
 

 

 

  Heel raise test for flexible flatfoot   Heel raise test for rigid flatfoot  

 

 
A stiff flatfoot is the one that cannot be corrected by manipulation as suggested above and it suggests an underlying pathological disorder such as a “tarsal coalition” in which the bones of the hind foot are joined abnormally together. This needs specialist investigation.
 
     
2.
  • Acquired flat foot – These people are born with normal feet. However they acquire flatfoot in adult life. If could be either because of posterior tibial tendon disease or because of arthritis of the foot. It can also be associated with rheumatoid arthritis or diabetes.  This type of flatfeet is progressive and can lead to significant disability if not treated early.
 

 

A 'good' flat foot is bilateral, painless, has been present a long time, does not progress and is flexible (corrects fully). This type does not require treatment. This is a common type of flat foot in children.

Bad flat foot is painful and as the deformity progresses there is curling out of the heel. It is correctable by standing on tip toes initially but as condition worsens it becomes fixed.

 

How can I tell if I have flat feet?

Flat feet are easy to identify while standing or walking. To find out - stand on tiptoe or push your big toe back as far as possible. If the arch of your foot appears, it means that you have flexible flat foot. If the arch does not appear, you are likely to have stiff flat foot. In such cases your foot is likely to over-pronate or become flat when you walk or run. It can be difficult to tell if a child has flat feet as the arches may not fully develop until the age of 10.

 

When should you consult a foot specialist if you have flat feet?


1. If you were born with normal feet but your foot have recently changed shape.
2. If you had no pain before but have now develop pain.
3. If your heel starts to curl out.
4. If your flatfoot was flexible before but has now becomes fixed in this position.
5. If the flat foot problem is only on one side only (unilateral).

 

 
Comparing normal and flatfoot
  Comparing normal and flatfoot from behind  
 
A right sided flat foot with normal left side.
 
A left sided flatfoot with normal right side. Note the outward curling of heel.
 

 

 

What is the cause of bad or Adult acquired flat foot?

 

 
Tibialis Posterior dysfunction leads to flatfoot
     
 

 

     

One of the most common causes for a flat foot in the adult is a rupture or disease of the posterior tibial tendon. The posterior tibial tendon (along with other supportive ligaments) is responsible for maintaining the arch of the foot. This tendon passes behind the ankle and wrapping around the back of one of the bones on the inside of the ankle called the medial malleolus. There are certain individuals who seem to be more prone to developing a rupture of the posterior tibial tendon. These include women who are overweight and those people who have a flat foot that has been present since early adulthood or even childhood. In these individuals the posterior tibial tendon may be prone to stretch out and tear. As the tendon tears, its supportive function is lost. This causes pain and the foot begins to roll inward and heel outwards leading to flattening of foot. 

 

What problems are faced by adult patients developing flat foot?

 If you have flat feet you may experience pain in any of the following areas:


1. inside of your ankle
2. arch of your foot
3. the outerside of your foot
4. calf (the back of your lower leg)
5. knee, hip or back
 

Some people with flat feet find that their weight while walking is distributed unevenly, particularly if their heel is curling out. If your heel has changed shape, it is likely that your shoes will wear out quickly. Also new position of foot and the heel affects your walking and puts pressure on the knees, hips and back causing pain in these areas. Change in shape of foot can also cause damage to your ankle joint and Achilles tendon (the large tendon at the back of your ankle).

 

What happens if I leave my flat foot untreated?

This will be somewhat dependent upon the cause of flat foot. Most commonly especially if the cause is tibialis posterior tendon dysfunction a progressive deterioration of the rest of the hindfoot and ankle occurs. Over what time period this occurs is not definitively known. There are high chances that the progression may lead to a rigid, painful hindfoot arthritis and deformity. The fixed and arthritic flat foot may require at least a triple fusion (see below) and at worst a triple and ankle fusion (or replacement) combined (If the ankle has become involved). These are very extensive and "higher risk" type of surgery than treating this condition early with a tendon reconstruction.

 
Advance flatfoot with arthritis. patient is wheelchair bound.
     
 
Bilateral advanced flat foot with hindfoot arthritis.This patient is unable to walk and is wheel chair bound.
     

 

What treatments are available for a painful flat foot? 

 

Orthotics for Flat Foot 

Orthotic treatment by Podiatrist may help by recreating an arch in a mobile flat foot and hold it in a corrected position.

 
 Rigid Orthotic support for flat foot
  Correction of flatfoot with orthotic support  

 

The drawback of orthotic support is that the effect is only present when it is worn in the shoe and ceases if it is not worn.

Whether orthotic treatment prevents the progression of a deformity or not is not definitively known. Once the foot becomes flat, there is very little that can stop it from flattening out further. This occurs as one stands, as the weight of the body and the mechanical effect of this weight pushes the foot out further.

In the flexible flat foot orthotics should usually be the recommended first line of treatment. 

In a rigid and arthritic flat foot orthotics cannot correct the foot position but they may be able to improve pain.

 

OPERATIVE MANAGEMENT (FLAT FOOT SURGERY)

The following refers to the two commonest scenarios which comprise the bulk of operative cases.

These are:

1. A flat foot due to Tibialis posterior dysfunction in which an orthotic has failed to improve pain and walking. These type of patients are treated with Tibialis posterior reconstruction to recreate medial arch and calcaneal osteotomy to correct outward curling of heel.
2. The rigid and painful arthritic flat foot.

 

Tibialis posterior reconstruction


1. How does an unhealthy "Tib Post" lead to a flat foot?

Tibialis posterior tendon attaches to the middle of the foot and is responsible for maintaining the arch. When it becomes diseased the elastic structure of the tendon is replaced with abnormal scar tissue. This abnormal tendon stretches out under the weight of the body and is unable to maintain shape of the foot allowing it to stretch out. Other tendons which are working pull the foot in a way that heel curls out.



2. What is involved in reconstructing the tendon?

The diseased tendon is removed as it is inflamed and giving rise to pain. An adjoining tendon is moved into its place (the FDL, Flexor Digitorum Longus). This tendon slowly takes over the function of diseased tibialis posterior tendon.  

 
FDL tendon used for flatfoot reconstruction
     

As mentioned before the heel curls out to compensate for the flattening in the arch and hence it is quite common to do an osteotomy of heel bone and move it back into a correct position for normal walking.

 

3. Can tendon be repaired instead of using an adjoining tendon from the foot?

As the tendon becomes diseased it looses its elastic recoil and stretches out (like a stretched out spring or a rubber band). It is important for tendon to have its normal elasticity to maintain movements of the arch of the foot during walking. As the stretched out rubber band or pulled out spring cannot be repaired to work as before – no amount of reapir can bring back normal elasticity and recoil in the tendon.

 

Case example – showing clinical picture before and after operation.

  Picture showing flatfoot   Picture showing flatfoot correction after surgery  
 

(left side) Clinical Picture of a patient with acquired flat foot due to posterior tibial tendon disease on the left foot. Note that the left heel is curling out and has changed shape. On the right is the same patient 1 year after reconstruction with the FDL tendon. Note that the arch and heel position are back to normal and his pain completely disappeared.

 

     
X-ray showing flatfoot
 
         
     
X-ray showing flatfoot correction after surgery
 
 

Before and after surgery x-ray pictures. Note the improvement in arch and the overall shape of the foot.

 

After the operation

On the Day 

Pain relief

After surgery your foot will feel numb and feel pain free because of the nerve block done before surgery. You will also be given pain killer tablets which keeps you painfree when the block has worn off in 8-10 hrs.


Your foot

Will be in Plaster cast.


Mobility 

You will be walking with the help of cruches for first 6 weeks after surgery. A physiotherapist will instruct you on the use of crutches the day following surgery. You will be non weight bearing on the operated foot for a period of six weeks.


Length of stay

One or two days depending upon comfort and mobility.

 

At two weeks 

You will require an outpatient assessment and wound review. Dissolvable sutures are normally used .Your plaster will be changed and non weight bearing crutch walking will continue for another four weeks. 

 

At six weeks 

You will require an outpatient assessment and check x-ray to confirm union of the calcaneal osteotomy. 

At this stage you will be able to return to the orthotic which by itself has failed to control your foot preoperatively. It may require some adjustment by our orthotist. This should be worn for all weight bearing activity.

 

4.What are the chance of success after tendon transfer operation?

  • The chance of significant reduction in pain and improvement in function is of the order of 85-90%.
  • The chance of a persisting correction in the shape of the foot is about -80%

 

The stiff (non correctable) and painful arthritic flat foot

This most commonly occurs as a result of arthritic changes in the subtalar joint plus or minus the midfoot joints. There are many pathologies which may ultimately result in this situation. The most common are progression following a Tibialis posterior dysfunction, following Calcaneal or other Midfoot fractures, as a manifestation of inflammatory joint disease(such as Rheumatoid Arthritis), or as a result of a tarsal coalition.

 

     
X-ray showing Rigid flatfoot with Arthritis
 
         
     
 X-ray showing Rigid flatfoot reconstruction with Triple Arthrodesis
 
 

X-ray of the flat foot patient before and after operation. Note that she has arthritis in subtalar and talonavicular joint due to longstanding tibialis posterior dysfunction. The ankle joint is still well preserved. Her walking and pain improved completely after a successful triple fusion operation.

 

  left sided arthritic subtalar and midfoot joints   improvement in shape after operation  
 
left sided arthritic subtalar and midfoot joints
   
   
 
Left sided arthritic subtalar and midfoot joints. 
 
improvement in shape after operation