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A flatfoot is a foot in which the normal arch along the inside of the foot is reduced or absent. Many adults have naturally low arches and never develop symptoms or require treatment. However, in some people the shape of the foot changes progressively during adult life. This is now commonly referred to as progressive collapsing foot deformity (PCFD) and was previously called adult-acquired flatfoot or posterior tibial tendon dysfunction. It is a three-dimensional deformity that can involve the tendons, ligaments, bones and joints of the foot.
As the condition progresses, the heel may gradually turn outwards, the arch can collapse and the front of the foot may turn outwards. The posterior tibial tendon, which supports the arch, is frequently involved, but we now understand that failure of supporting ligaments and changes around several joints can also contribute. In more advanced cases, the deformity can become stiff and arthritis may develop within the affected joints.
Some people with flat feet have no symptoms at all and need no treatment. When symptoms develop, pain is commonly felt along the inside of the foot and ankle, particularly around the posterior tibial tendon. As the deformity progresses, pain may also develop on the outside of the ankle or hindfoot as the bones and soft tissues become crowded. Patients may notice increasing difficulty with prolonged walking or standing, reduced walking distance, weakness when pushing off the affected foot and progressive change in the shape of the foot.
The important issue is therefore not simply whether the arch looks flat, but whether the foot is painful, progressively changing shape or losing function. Assessment by a foot and ankle specialist determines which parts of the deformity are involved, whether the foot remains flexible and whether arthritis is present. Weight-bearing X-rays are particularly important because the position and relationship of the bones need to be assessed while the foot is carrying weight.
Most adults with flat feet do not require surgery. Treatment is usually directed at symptoms and may include appropriate footwear, insoles or orthotics, physiotherapy, stretching and strengthening exercises, activity modification and, in more symptomatic cases, a supportive brace. Non-operative treatment is particularly effective in earlier and more flexible forms of the condition and should generally be tried before surgery is considered.
Surgery may be considered when significant pain and functional limitation continue despite appropriate non-operative treatment, or when there is a troublesome progressive deformity. The decision depends not only on the severity of symptoms but also on which components of the foot have collapsed, whether the deformity remains flexible, the condition of the joints and the individual patient’s health and functional requirements. There is therefore no single operation that is appropriate for every adult flatfoot.
The aim of surgery is to create a well-aligned, stable and comfortable foot. In a flexible deformity, reconstruction usually involves a combination of procedures rather than one operation. Depending on the individual deformity, these may include repositioning the heel bone with an osteotomy, correcting the alignment of the midfoot or medial column, repairing or reconstructing damaged ligaments, addressing the diseased posterior tibial tendon and lengthening a tight calf or Achilles tendon. Modern reconstructive principles favour preserving healthy joints and movement whenever this can provide a stable correction.
When the deformity has become rigid or significant arthritis has developed, preserving all of the affected joints may no longer be appropriate. In these circumstances, one or more painful or deformed joints may need to be fused to restore alignment and provide a stable, plantigrade foot. The precise combination of procedures is therefore tailored to the anatomy and severity of each patient’s deformity rather than applying the same operation to everyone.
Recovery depends considerably on the type of reconstruction performed. Following many flatfoot reconstructions involving bone correction and tendon or ligament reconstruction, the foot is protected in a cast or boot and weight-bearing is restricted during the early healing period. Traditional protocols commonly involve approximately 6 weeks of non-weight-bearing or very limited weight-bearing, followed by progressive protected weight-bearing once satisfactory healing has been demonstrated. Reconstructions involving joint fusion may require a longer period of protection.
Once healing permits, rehabilitation concentrates on restoring movement where appropriate, rebuilding strength, improving balance and retraining walking. Recovery is gradual rather than immediate. Although everyday function improves progressively over the first few months, strength, walking endurance and swelling can continue to improve for many months after a major flatfoot reconstruction. The exact rehabilitation programme should therefore be individualised according to the procedures performed and evidence of healing.
Elevation and swelling control are particularly important during the early postoperative period. Follow-up appointments are used to assess the wounds, monitor correction and check bone healing with X-rays before weight-bearing is advanced. Physiotherapy is introduced at the appropriate stage to restore movement, strength, balance and walking pattern. Return to driving, work and sporting activity varies considerably according to the operation performed, which foot has been treated, the patient’s occupation and the progress of healing.
The aim of treatment is not simply to make the arch look more normal. The more important objectives are to reduce pain, improve function and achieve a stable, well-aligned foot that can support everyday activities. Surgery can substantially improve symptoms and function in appropriately selected patients, but recovery from a major flatfoot reconstruction takes time, and some residual swelling, stiffness or limitations may remain. Current expert consensus emphasises obtaining a stable and appropriately aligned foot while preserving joint movement whenever it is reasonable to do so.
Mr Shalaby regularly performs surgery for adult flatfoot and progressive collapsing foot deformity as part of his specialist foot and ankle practice in Edinburgh, including both joint-preserving reconstruction and more complex corrective procedures when required. He also assesses and treats suitable patients during his international specialist visits. If you would like an expert assessment of your condition or wish to discuss whether surgery may be appropriate for you, you can click here to book a consultation.
