Flat foot surgery

Flat foot surgery

Flat foot surgery

Flat foot surgery

Flat Foot Surgery

Many of us have flat feet, which means we have either a very low, or non-existent arch in our feet. Most of the time, this doesn’t cause us any issues, but some people do experience symptoms with their flat feet, such as pain, overload of their Achilles tendons, foot joint arthritis, bunions, and tibialis posterior tendinopathy.

What causes flat feet?

We’re all born with flat feet, and our arches develop in early childhood but 1 in 5 people will have flat feet going into adulthood. Sometimes this is because of a familial, or inherited foot shape, but flat feet can also occur in adult life, which is sometimes known as ‘fallen arches’, or adult-acquired flat feet.

What are the types of flat feet?

This is the most common kind of flat feet, and it usually starts to cause symptoms as children approach their teenage years and worsens into adulthood. Tendons and ligaments that would normally support the arch on the inside of the foot become stretched, or even torn. This can cause pain in the arch of the foot, shin splints pain with activities such as running, and even knee pain.  Some cases are hereditary, and sometimes a genetic problem, such as Down’s syndrome or Marfan’s syndrome can predispose to this condition, but many teenagers are simply hypermobile (double-jointed).  Often these patients will complain of pain on the lateral (outside) side of the foot, because of impingement, and/or the medial (inside) side of the foot and the pain may stop them from being able to play sports and take part in activities they enjoy.

This is as it sounds- a flat foot, that lacks flexibility. It’s often caused by abnormal connections between bones (such as a ‘tarsal coalition’), or a malformed bone, which limits foot movement (such as a vertical talus). Children with rigid flat feet may develop calluses on the soles of their feet, and pain may make it difficult for them to run and play. Finding shoes that fit can also be a problem.

This condition is now also known as ‘Progressive Collapsing Foot Disorder’ and has previously been known as ‘Tibialis Posterior Dysfunction or insufficiency’. In this condition, structures within the foot (such as the tibialis posterior tendon, or the spring ligament) begin to fail. Sometimes this can rapidly escalate if there is tearing of a tendinopathic tendon, and it can be contributed to by high blood pressure and obesity. These patients initially have flexible feet, but if osteoarthritis develops, the feet become more rigid.

How is flat foot diagnosed? Are any investigations needed?

When you come to clinic, I’ll want to hear about you as a person, how your feet are affecting your life, and what you have tried so far in terms of treatment.

I’ll examine you carefully, watching how you move, and looking in detail at your foot posture, flexibility and movement.

I’ll routinely ask for weight-bearing X-rays, and sometimes imaging such an ultrasound, MRI, or CT scan may be needed to better understand the bony architecture and soft tissue structures of your feet, so we can understand what needs to be done to best correct the problem.

When is surgery required for flat feet?

Physiotherapy to strengthen the muscles that support the feet and ankles, and orthotics to help improve the foot alignment is all that many people need to manage minor symptoms of flat feet. Staying lean and fit will also help.

Sometimes, however, a person may experience painful feet that is so intrusive that surgery may need to be considered.

If a child isn’t improving with conservative measures, we try to wait until they are in their early teens (e.g. aged 14) before carrying out surgery, to ensure their feet have sufficiently grown.

For adults who have progressive collapsing foot, the sooner we intervene, the better, to help prevent further progression and development of arthritis.

Surgery for flat feet

Everyone’s foot shape is unique, and I use different types of surgery to correct the flat foot, depending on the severity and the person’s foot shape.

In adolescents, I may recommend calcaneal lengthening combined with a Cotton osteotomy, sometimes with a calf release. In adults, I tend to recommend a minimally invasive calcaneal osteotomy, with a Cotton osteotomy, sometimes with a tendon transfer or spring ligament reconstruction.

Calcaneal (or Lateral Column) Lengthening Osteotomy

This is designed to correct the flattening of foot and to bring it into a straighter alignment.  It’s usually carried out under a general anaesthesia. An incision is made on the outside (lateral) side of the foot, the heel bone is cut across, and a new piece of bone (typically a graft taken from the pelvis) is inserted between the two cut ends. A pin holds the bones in place while they heal, which is then removed in clinic at 6 weeks after surgery.

Cotton (or Medial Cuneiform Opening Wedge) Osteotomy

The medial cuneiform is a bone at the top of the arch in the foot, and this surgery involves a vertical cut down through the centre of the medial cuneiform, and in adolescents, a bone wedge (from their pelvis) is positioned in between the two cut ends of the bone. I don’t use metal work for adolescents, but if the patient is an adult, I may use a plate and screws to fix the ends of the bone.

Flexor Digitorum Longus (FDL) Tendon Transfer

If a person’s tibialis posterior tendon is stretched, torn, or failing to support the arch, then a tendon transfer can enable the flexor digitorum longus (FDL) tendon to do the work of the failing tibialis posterior tendon. An incision is made on the inside (medial) side of the foot, the tibalis posterior tendon is debrided, and the FDL tendon is cut and then attached to the navicular bone (where tibialis posterior inserts).  Sometimes this surgery is performed with calcaneal osteotomy procedure.

Spring ligament reconstruction and fusion surgery may also be required.

How long does it take to recover after flat foot surgery?

A good deal of adult-acquired flat foot can be carried out fully or partly by minimally invasive techniques.

After the surgery you’ll spend a little while in the recovery area, and then you’ll come back to the ward. Your foot will be in a plaster cast which will need to remain on for six weeks. A physiotherapist will show you how to use crutches, and it’s very important that you keep weight off your surgery leg for the entire six weeks. When you’re not needing to get about, you should elevate your foot so that it’s higher than your heart to reduce swelling and aid recovery. You’ll be given painkillers, and you should find that your foot starts to feel more comfortable towards the end of the first week.

We’ll meet again in clinic at the three-week stage, and I’ll check the wounds and remove your stitches. You’ll have a new below knee lighter plaster cast put on, and we’ll meet again three weeks later. We’ll take X-ray, and if all is going well, you’ll come out of the cast and go into a boot for a final six weeks, and you can start physiotherapy. You’ll be fully weight-bearing at this stage.