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The value of healthy feet – a clinical picture of talipes plano-valgus or flatfoot

Occurrence of flatfoot

"A beautiful foot is a great gift of nature." (J. W. von Goethe)

Our feet carry us through life. Their longitudinal arch is perfectly designed to cushion bodyweight and push us off the ground with momentum during the movements of walking. When feet are healthy, we tend to overlook this impressive piece of engineering. With foot malpositions, however, painful complaints can arise, often leading to severe impairment.

One of these malpositions is so-called ‘flatfoot’, which affects about 13-15% of all adults; and for 1-2% of them, the consequence is clear discomfort.

Symptoms: How does the patient recognise talipes plano-valgus or flatfoot?

The most commonly used term, flatfoot, summarizes different forms of foot malpositions and deformations. We would like to briefly highlight the most important ones.

The term pes plano-valgus refers to the rear part of the foot bending outwards (pes valgus), causing an outward displacement of the heel.

The second component of this malposition is the lowering of the arch of the foot (pes planus). The midfoot then rests on the inside, which becomes visibly obvious when you look at the inner side of the affected foot in a standing position.

In addition, an abduction develops, i.e. the foot points outwards when viewed from above (pes abductus).

Flatfoot is a common malposition of the foot, typically affecting small children and the elderly. During infancy, lowered arches are a normal physiological occurrence. But the longitudinal arch of a healthy foot should then develop normally until teenagehood.

Possible damage resulting from flatfoot / talipes plano-valgus:

  • Pains while walking
  • Heel spur
  • Achilles tendon problems
  • Deformation of the big toe joint (hallux valgus, or bunion) and the small toes
  • Joint stress leading to cartilage wear in the joints (arthrosis/arthritis)
  • Overloading or tearing of the flexor tendon (tibialis posterior dysfunction)

Causes of talipes plano-valgus or flatfoot

One must distinguish between flatfoot as a malposition in children‘s feet and acquired flatfoot in adults. As mentioned above, the child's arch in most cases rises up by itself, making treatment unnecessary. However, it can be helpful for the natural development of the feet to engage the child in sports and barefoot activities to strengthen the musculoskeletal system. It is important to use the growth phase for exercise stimuli and training, as this is the only period during which the arches of the feet can be raised.

Orthopedic insoles should only be used specifically to support the ankles, for example in the case of painful, pronounced talipes valgus.

The situation is quite different if bony malformations (e.g. bone maturation / tarsal coalition) lead to developmental disorders of the foot. If these are not recognized in time, they can lead to complaints later in adult life.

Once the growth phase is completed in adolescence and early adulthood, flatfoot and talipes valgus can no longer be permanently treated with non-surgical means.

The lowered arch in an adult's foot is caused by a number of possible external factors. Besides a family predisposition, those may be:

1. Damage to the bone:

  • heel bone fractures
  • diseases of the bone (such as bone necrosis from circulatory disorders)

2. Damage of the musculature/tendons:

  • tendon tear
  • wear due to increasing age
  • muscle weakness
  • paralysis / neurological disorders

3. Damage to joints and ligaments:

  • ligamentous laxity (connective tissue weakness) with instability in the lower ankle joint
  • ligament overstretching / injuries (ankle sprain)
  • Joint wear and tear / rheumatoid diseases

In addition to external factors such as overweight or frequent, prolonged standing (e.g. due to working conditions), hereditary predispositions may include a genetic susceptibility to weaker connective tissue and weaker ligaments.

Progressive stages of flatfoot

The development of acquired adult flatfoot is divided into four stages. Some symptoms occur throughout all stages – crucial for diagnosis is knowing how advanced the foot malposition is. The specific stage determines the appropriate therapeutic measures.

Stage 1:

In the first stage, the patient can still actively straighten the longitudinal arch of the foot; the foot position is still within normal limits. The tendon appears to be irritated, which can lead to inflammation of the tendon sheath or incipient degeneration of the tendon.

Frequent first-stage symptoms:

  • Pain on the inside of the hindfoot
  • Swelling beneath the ankle
  • Beginning of muscle weakness
  • Reduced load capacity

Stage 2:

The second stage is marked by the beginning of malposition of the foot. Susceptibility to tendon tears increases, as does muscle weakness.

Frequent second-stage symptom:

  • Increasing pain on the inside of the hindfoot
  • Severe swelling under the ankle
  • Significant muscle weakness
  • Flexible flatfoot
  • Incipient equinus deformity
  • Instability

Stage 3:

In the third stage a foot malposition becomes distinct. The rear of the foot is visibly bent outwards, the inner arch is lowered and the middle/forefoot is spread (turned outwards).

Frequent third-stage symptoms:

  • Severe pain on the inside and outside of the hindfoot
  • Pronounced swelling beneath the ankle
  • Contracted (fixed) talipes plano-valgus
  • Pronounced equinus deformity

Stage 4:

In the fourth stage, the foot malposition becomes even more pronounced. This stage is often accompanied by an inflammation of the joint (secondary arthrosis), restricting freedom of movement.

Frequent fourth-stage symptoms:

  • Widespread pain in the ankle joint and heel or sole of the foot
  • Massive swelling beneath the ankle
  • Fully contracted, spread-out talipes plano-valgo-abductus position
  • Extremely developed (fixed) equinus deformity

Treatment options for flatfoot

Treatment for flatfoot depends on the diagnosed stage or degree of the malposition. To determine the stage, we examine the foot in lying and standing positions (under load) and check its mobility. Further information can be obtained from an X-ray image taken while the foot is under full weight bearing.

Especially during the first stages of flatfoot, conservative (i.e. non-operative) measures such as orthopaedic insoles and strengthening exercises, as well as physiotherapy, can offer valuable support.

Operative treatment in the progressive stages:

Stage 1:

When conservative means of manageing flatfoot are exhausted, a smoothing and cleaning of the strained, irritated tendon (endoscopic tenosynovectomy) can often bring relief and support the patient with straightening the arch of the foot. An alternative to endoscopic surgery at this stage is open tendon surgery, which maintains the functionality of the tendon.

An important measure at this stage is examination of the ligament’s stability. In case of instability, an operative ligament reconstruction surgery (ligamentoplasty) is advised, reconstructing the weakened spring ligament. This helps counteract a further lowering of the foot’s arch as well as any subsequent malpositioning.

Stage 2:

At this stage, with instability being a constant companion, reconstruction of the ligamentous apparatus and muscle-tendon function is advised. In order to enable mobility and actively raise the arch, tendon transfer is usually necessary. An adjacent tendon in the body is inserted into the tibialis tendon, which is responsible for the active stabilization and straightening of the longitudinal arch of the foot.

Very often, however, soft tissue measures are no longer sufficient and bony corrections are additionally necessary. These corrective osteotomies are joint-preserving surgical measures, maintaining the function of ankle joints.

In such cases the Foot and Ankle Center Berlinapplies an adjustive combined realignment, comprising an individually adjustable Rhise-factor, which additionally supports the stabilizing effect of ligament surgery.

Stage 3:

In the case of a pronounced malposition in stage 3, the joint-preserving bone corrections (corrective osteotomies) introduced in stage 2 become absolutely necessary as a biomechanical therapy procedure to correct the malpositions.

In cases of pronounced instability and/or considerable contracture (soft tissue scarring and incapacity for muscle tendon regeneration, as in the case of underlying rheumatic diseases), the stiffening of a facet joint (arthrodesis/fusion) may be necessary to achieve a sustainable result. This completely preserves the mobility of the upper ankle joint.

A selectively-adaptive facet-fusion developed by Dr. Boack, combined with a joint-preserving adjustment, can further add to a stabilizing effect, allowing for mobility of the foot with almost no noticeable impairment.

Stage 4:

If secondary arthrosis of the ankle joints occurs in stage 4, in addition to joint-preserving bone corrections (corrective osteotomies) (see stages 2 and 3), a stiffening of the affected facet joints (arthrodesis) is also necessary in order to enable a good positioning and pain-free function of the leg/foot.

Arthrodesis is one of the most important procedures in foot and ankle surgery. There are 26 different joints in the foot and ankle. By targeted stiffening of facets, the individually-adaptive technique applied at the Foot and Ankle Center Berlin achieves significant stability, a good position of the foot, and, by relieving pain, an improvement in its functionality – so long as the upper ankle-joint is retained.

In cases where the upper ankle joint is also compromised, we usually recommend at this stage the targeted use of an ankle replacement rather than complete stiffening, thus avoiding overload of the neighboring joints and enabling a largely natural motion sequence.

Having conducted over 1,200 ankle endoprosthesis implants, Dr. Boack is one of the most experienced surgeons worldwide in this field.