Ankle and Foot Clinic of Idaho

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Conservative treatment for PTTD is immobilization in a walking cast.  If the tendon remains non-functional and surgery is not an option, then long term treatment in an ankle-foot-orthosis is required.
If there is back pain and no pain or swelling at the ankle, then it may be associated with a lumbar spine mpingement.  The only treatment is to take the pressure off the spinal cord.  This is quite rare as we have only seen 2 cases of this in over 10 years of practice.

Surgical treatment

If conservative treatment fails then surgical treatment needs to be considered.  Surgical treatment depends on age, type of flat foot, and severity of the condition.
Youth:  As a general rule, if the growth plates are open then a subtalar joint arthroeresis is an option.  This treatment has nothing to do with the growth plates, but is more associated with the foot’s ability to tolerate the implant.  Studies have found that adults do not tolerate this procedure, whereas children respond remarkably well.  These have been implanted in adolescents with closed growth plates with good success, but this is determined on a case by case basis.  The advantage of an implant is the recovery.  Patients can walk immediately with very fast return to full activity.
Adults:  Flat foot reconstruction in adults requires a repositioning of the heel bone.  There are often additional procedures to support the arch, such as repair 
or transfer of the tendon in PTTD.  This is only done if the joints are still flexible and arthritis is absent.  These procedures have an excellent track record for “rebuilding” the arch and decreasing pain permanently. Occasionally the joints are too stiff or arthritic.  The recommended surgical treatment is a hindfoot fusion. If done correctly, this can significantly reduce or eliminate pain.

Tarsal coalitions can be resected depending on the type and severity.  Some require repositioning the foot in a better position and fusing the joints.

Causes of flat foot

Conservative treatment

Conservative treatment is often very successful in managing symptoms and allowing function, including sports, with minimal pain.  The most successful treatment is unquestionably a good orthotic (arch support). Over the counter devices may help and are worth a try, but in reality, they often do not provide enough support. Custom orthotics are made for individuals that are not getting relief with over the counter devices.


So how do you know if you should seek treatment for a non-Adult Acquired flat foot?  Here are some questions to help guide your decision if you feel you have a low or no arch:
  1. Do you have pain in the feet, ankles, legs, or lower back when you walk or stand?
  2. Do you get cramps in your feet or legs, even when you are not on your feet such as at night?
  3. If you are in relatively good physical shape and do not have lung, artery, or heart problems, do your feet and legs get tired with prolonged standing or walking?
  4. Do you avoid activities that involve prolonged walking or standing because your feet and legs get tired?
  5. Do you have a difficult time finding shoes that are comfortable?

Flat feet

  1. Genetic-  This is the most common cause of flat foot.  It can be related to hypermobile joints, a tight Achilles tendon, or bone and joint position.
  2. Tarsal coalition- An abnormal bone or fibrous connection between two separate bones.
  3. Posterior Tibial Tendon Dysfunction (PTTD)- See below.
  4. Spinal impingement- See below.
Feet are often considered flat when the arch is much lower than what is considered “normal”.  The inherent problem with this definition is that a “normal” foot has never been defined.  A better way to look at this is that a flat foot or low arch actually allows more instability of the foot.  This instability exerts additional stresses on the joints, ligaments, tendons and muscles associated with the foot.  Many individuals can compensate for this instability and have no problems with their flat feet.  The only reason to seek treatment is when there is pain or limitation associated with this instability.  This however, can be a gray area.  Individuals with symptomatic flat feet may not have pain, but commonly feel tired more quickly, especially on longer walks or engaging in sports. This is especially true with children and adolescents.

Progressive flat foot (Acquired adult flat foot)

Some individuals may notice their foot getting progressively flatter without injury or change in daily routine.  This is often accompanied by a painful and swollen ankle.  This is a sign of a much more serious condition called Posterior Tibial Tendon Dysfunction (PTTD).  The Posterior Tibial Tendon is a large tendon on the inside part of the ankle, responsible for controlling our foot when we step down.  It is possible to injure or rupture this tendon without traumatic injury such as an ankle sprain.  In fact, most patients do not remember any injury to the ankle and describe a gradual pain and swelling.  If this condition describes you, DO NOT WAIT TO GET TREATMENT.  If this is treated early, chances of healing conservatively are much improved.