Painful Flat Feet (Fallen Arches)
Understanding painful flat feet and the treatment options available
Many people have flat feet and never experience any problems. In fact, some people have had relatively low arches all their lives and remain entirely pain free.
However, for others, the arch gradually collapses over time and becomes painful. The foot may begin to roll inwards, walking becomes more difficult, and activities that were once taken for granted can become increasingly uncomfortable.
This condition is often referred to as adult acquired flatfoot, fallen arches, or posterior tibial tendon dysfunction (PTTD). More recently, doctors have adopted the term progressive collapsing foot deformity (PCFD). Although the terminology can sound alarming, the underlying problem is usually straightforward to understand.
One of the main structures connected in to the arch is a tendon called the posterior tibial tendon (tibialis posterior). This tendon runs behind the inside of the ankle before attaching to the foot. Over time, it can become stretched, weakened or, occasionally, tear. As this support begins to fail, the arch gradually lowers and the heel drifts outwards. Swelling can develop around the inner ankle and pain radiate up the calf
Patients often tell me that they first noticed aching and swelling along the inside of the ankle. Others become aware that they can no longer walk as far as they once could. Some find it increasingly difficult to stand on tiptoe on the affected side, while others notice pain developing on the outside of the ankle as the foot becomes more misaligned.
The condition usually develops gradually over months or years.
Why has this happened?
There is rarely a single explanation.
Age-related changes within the tendon can contribute, as can previous injury, family tendency, inflammatory arthritis, diabetes and excess body weight. Occupations involving prolonged standing may also place additional strain upon the structures supporting the arch.
Importantly, this is not something patients have caused by doing the wrong exercise, wearing the wrong shoes or failing to seek treatment soon enough. It may just be you are double jointed and the ligaments have stretched.
Do I need surgery?
No.
In fact, many patients improve considerably without an operation.
Flatfoot reconstruction is generally reserved for those whose symptoms continue to interfere significantly with everyday life despite sensible non-operative treatment.
There is often a misconception that surgery should be performed simply because the foot looks flatter. In reality, treatment decisions are guided primarily by symptoms rather than appearance.
The aim is not to create the “perfect arch”. The aim is to achieve a comfortable, functional and reliable foot.
What are the alternatives?
There is no single treatment that works for everyone, and often the best results come from combining several simple measures.
Many patients are surprised by how much difference sensible footwear can make. Supportive shoes with a firm heel and relatively stiff sole often improve comfort considerably compared with soft, unsupportive footwear.
Insoles or orthotics can provide additional support beneath the arch and help reduce strain on the damaged tendon. Some patients benefit from simple off-the-shelf devices, whilst others require more customised support.
Physiotherapy can also play an important role. Improving calf flexibility, strengthening the muscles supporting the foot and working on balance can all contribute to improved function.
For patients with more advanced symptoms, an ankle-foot brace can provide excellent pain relief and may delay, or even avoid, the need for surgery.
Simple pain relief and anti-inflammatory medication may sometimes be appropriate, provided these are medically suitable for the individual concerned.
Most importantly, many patients do not require surgery at all.
When should surgery be considered?
Surgery may be appropriate when pain continues despite appropriate non-operative treatment and begins to affect quality of life.
Patients often describe limiting walks, avoiding holidays involving prolonged sightseeing, struggling at work, or finding themselves unable to enjoy the activities they previously took for granted.
Provided the foot remains sufficiently flexible, reconstruction can restore alignment and improve function.
The decision to proceed is never made lightly and should only occur once the likely benefits, alternatives and recovery have been carefully considered.
Flat Foot Reconstruction
One of the commonest misconceptions is that surgery simply involves repairing a damaged tendon.
Unfortunately, it is rarely that straightforward.
As the tendon weakens, the bones and joints of the foot gradually drift out of position. Successful treatment therefore requires us not only to address the tendon itself but also to correct the alignment of the foot.
Flatfoot reconstruction is therefore tailored to the individual patient. Not every person requires every component of the procedure.
Commonly, reconstruction involves a combination of:
- Calcaneal osteotomy
- FDL tendon transfer
- Internal Brace augmentation
- Spring Ligament tightening
- Cotton osteotomy, when required
Video 2 – Calcaneal Osteotomy
Osteotomy
The calcaneus is the heel bone.
During this procedure, the heel bone is divided in a controlled manner and shifted inwards before being secured with screws.
Although the idea of cutting and repositioning bone understandably sounds daunting, this step is often one of the most important aspects of the reconstruction.
By moving the heel back underneath the leg, the forces passing through the foot become much more favourable. The reconstructed tendon is placed under less strain and the risk of recurrent deformity is reduced.
In simple terms, this procedure corrects the foundations upon which the rest of the reconstruction depends.
Tendon Transfer
FDL stands for Flexor Digitorum Longus.
It sounds rather alarming when described as a tendon transfer, but it is a well-established and widely used technique.
The tendon normally helps curl the lesser toes. Because several tendons contribute to this function, the FDL can be redirected to support the arch without causing significant disability.
The diseased posterior tibial tendon is addressed and the transferred tendon is attached to help restore support to the inside of the foot.
Most patients notice no meaningful change in the way their toes function
Video 1 – FDL & Spring Ligament Reconsturction
Internal Brace Augmentation
In all cases I use an Arthrex ‘Internal Brace’, used to provide additional support to the reconstruction.
This consists of a strong synthetic ribbon secured to bones using specialised absorbable bone anchors.
It does not replace the body’s own tissues. Instead, it reinforces the repair during healing and provides an additional layer of stability.
Whether an Internal Brace is appropriate depends upon the quality of the tissues and the nature of the deformity being corrected.
Cotton Osteotomy
Some patients continue to demonstrate residual collapse of the front of the foot even after the heel has been corrected.
In these circumstances, a Cotton osteotomy may be recommended.
This involves making a controlled cut in one of the bones within the midfoot and inserting a small wedge to improve alignment.
Not everybody requires this additional procedure, but when indicated it can fine tune the reconstruction and improve the overall balance of the foot.
What should I expect after surgery?
Recovery following flatfoot reconstruction requires patience.
This is major reconstructive surgery rather than a minor procedure, and improvement occurs gradually.
For the first couple of weeks, the foot is usually protected within a splint or cast. Elevation is important and patients generally remain non-weight bearing during this period
Plaster Cast 6 weeks in total
Following wound review, a cast or walking boot is usually applied. Most patients continue to avoid weight bearing for approximately six weeks, although this may vary depending upon the procedures performed.
Boot for 2-3 more weeks
Gradually, weight bearing is reintroduced and physiotherapy begins. Strength, balance and confidence improve steadily over the following months.
Many patients are walking comfortably by three to six months. However, swelling can persist for longer and the final result may not become apparent for nine to twelve months.
Although this recovery can feel lengthy, most patients feel that time passes more quickly than they initially anticipated.
What are the risks?
All surgery carries risk, and flatfoot reconstruction is no exception.
Potential complications include infection, blood clots, delayed wound healing, nerve irritation, prolonged swelling, stiffness, failure of bone healing, persistent pain, recurrence of the deformity and, occasionally, the need for further surgery.
Fortunately, serious complications are uncommon.
Every effort is made to minimise risk through careful planning, meticulous surgical technique and appropriate rehabilitation.
What results can I realistically expect?
The aim is improvement rather than perfection.
A successful outcome generally means less pain, improved walking tolerance, better alignment and an enhanced ability to participate in everyday activities.
Most patients remain aware that they have undergone major surgery. Some degree of stiffness, intermittent swelling or footwear limitation can persist.
However, in appropriately selected patients, flatfoot reconstruction is associated with high levels of satisfaction and many tell me that they wish they had sought help sooner.
Special Note
The information provided above is intended to help patients understand the condition and the treatment options available.
Some patients will wish to know more detail. Please ask, and I will be happy to discuss your individual circumstances and provide additional information.
Above all else, please do not proceed with surgery unless you are satisfied that you understand the proposed procedure, the alternatives available and the expected recovery.
Finally, this level of detail may understandably cause some patients concern or uncertainty. Please let us know if this is the case so that we can address any questions and help you make the decision that is right for you.
Next Steps…
If painful flat feet are affecting your quality of life, arranging a consultation allows us to determine the cause of your symptoms, discuss the full range of treatment options and decide together on the most appropriate plan to help you move forward with confidence.
Next steps…
If you would like to arrange a consultation to discuss your foot or ankle problems with Mr Williams, then please contact us.
