Flexible flatfeet in children don’t need treatment, because children’s feet grow to be normal feet regardless of the fact whether they are subjected to therapeutic exercise and footwear or not.
Adolescents and older adults having painless flexible flatfoot, also don’t need any therapeutic intervention.
In case of a painful flexible flatfoot or a rigid flat foot, some shoe insert, insole, orthosis or a modified shoe along with therapeutic exercise may help.
In case of a resistant flatfoot surgical treatment may be instituted.
11. Shoe Insert, Insole and Orthosis for Flatfoot:
Objective of using shoe inserts, shoe insoles and orthoses is optimal positioning of the foot, modification of symptoms and arrest of progression of the deformity.
During early phase of the deformity off-the-shelf orthoses and supports serve the purpose. As deformity progresses and becomes severe, custom made devices will be required.
The most appropriate arch support should have deep heel cup, limit abnormal posture and position of the foot and should be adjustable to cater for the individual needs of the subjects.
12. Shoes for Flatfoot:
A shoe that has the capacity to accommodate orthotics is the ideal shoe for flatfeet. These shoes usually have additional properties of limiting pronation, blocking over-pronation, good heel support, stiff sole underneath arch of the foot so that only forefoot flexes during walking.
In case of posterior tibial tendon dysfunction heel of the shoe should be set as low as possible for a heel higher than forefoot (positive heel) will cause the tendon to shorten hence rendering the stretching exercises ineffective. A person with posterior tibial tendon dysfunction associated flatfoot should gradually lower his heel over a period of time to a level lower than forefoot (negative heel). It will keep the tendon in stretched position.
13. Exercise for Developing Foot Arches:
Towel-rolling exercise is the best exercise for keeping the foot arches healthy and to make under developed arches more viable. As the age advances we gradually become less active leading to weakness and laxity of foot muscles. These muscles then cannot support the solid foot structures including arches, and lose the ability to provide spring mechanism that is required for efficient running and walking. This towel-rolling exercise is effective in restoring tone, strength and bulk of the foot muscles.
It is performed by sitting in a comfortable chair and spreading a towel in front of you on the floor. Place your toes on the edge of the towel that is near you. Now roll this towel by reaching out with your toes and then flexing these. Keep on doing this exercise until you have rolled the entire towel. While doing this exercise try to hold your toes for few seconds when in flexed position.
14. Flatfoot Surgery:
The objective of the flatfoot surgery is to attain normal or near normal foot alignment for better pressure distribution on the foot while standing and walking. This surgery is a complex procedure involving bone cuts for arch restoration along with arch-supporting tendon and ligament repair. Surgery is considered as a treatment option only if all the above mentioned treatments fail.
The surgical techniques that are used are as following:
A. Medializing Calcaneal Osteotomy:
This procedure is carried out in those cases who have their calcaneus (heel bone) slid out of the ankle and foot bone complex. In this procedure rear part of the calcaneus is cut and rest of it is pushed back into the bone complex followed by fixation of these bony structures with metal screws and plates.
B. Lateral Column Lengthening:
This procedure is carried out in patients with outward rotation of the foot. In this procedure anterior portion of the calcaneus (heel bone) is cut and a bony wedge (obtained from a cadaver or patient’s own hip) is placed in that cut. This wedge and rest of the bone complex is retained in place with the help of various implants such as metal screws and plates. This wedge results in overall lengthening of the heel bone causing the foot to slide back into its normal position.
C. Medial Cuneiform Dorsal Opening Wedge Osteotomy:
A collapsed arch can cause the big toe area of the foot to be elevated from the ground. This problem can be addressed with the help of 2 procedures and either of the 2 can be used. First one is medial cuneiform dorsal opening wedge osteotomy, which involves placement of a bony wedge over the medial cuneiform to push it down towards the floor. Screws and plates can also be used to maintain bony wedge. The second one is mentioned below.
D. First Tarsal-Metatarsal Fusion:
First tarsal-metatarsal fusion involves pushing down these bones in the middle of the foot around the joint and then fusing them in that position. Screws and plates can also be used to maintain bony fusion in place.
E. Tendon Procedures:
Tendons that can be maneuvered surgically to improve flatfoot include posterior tibial tendon, flexor digitorum (bends the little toes) and Achilles tendon. Posterior tibial tendon runs below the arch of foot and is overstretched and mechanically rendered ineffective in flatfooted patients. It usually has to be removed if it is thickened or torn. Then flexor digitorum tendon is transferred to its place in order to support the arch. Flatfoot is more often than not associated with tight Achilles tendon, which can be relaxed with lengthening procedures of the calf muscle fibers.
F. Ligament Procedures:
Spring ligament (supporting the arch) and deltoid ligament (on the inner side of the foot) bear the brunt of the stress put by abnormal mechanics of a flatfoot. These ligaments require repair when damaged or torn.
G. Double or Triple Arthrodesis:
In an advanced case of flatfoot, the deformity is usually rigid and inflexible. Arthritis of the joints of the foot in these cases also becomes a defining factor regarding treatment option for the flatfoot. These advanced cases get relief from fusion of one or more joints of the foot. This procedure is known as double or triple arthrodesis depending on number of joints fused.
15. Outcome and Prognosis:
Painless type of flatfoot does not require treatment and certain painful varieties can be treated without surgery. Painful flatfoot, which is resistant to other treatment interventions can be managed with surgery and it often improves pain and foot function.