Home > Foot Problems > Fallen Arches
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A fallen arch or "flatfoot" is known medically as pes planus. The foot loses the gently curving arch that should normally be found near the inner margin of the sole, just in front of the heel. If this arch is lost only when the foot bears weight (during standing), and it reforms when the foot is elevated off the ground, the condition is called flexible pes planus or flexible flatfoot. If the arch is lost in both foot positions ? standing and elevated ? the condition is called rigid pes planus or rigid flatfoot.
Flexible Flatfoot Or Flexible Pes Planus
Flexible flatfeet are considered to be a normal condition in young children. This is because the normal foot arch is not present at birth, and it may not fully form until sometime between ages 7 and 10. Even in adulthood, 15 percent to 25 percent of individuals have flexible flatfeet, and most of these people never develop symptoms. In many adults who have had flexible flatfeet since childhood, the absent arch is an inherited condition related to a generalized laxity (looseness) of ligaments. These individuals usually have extremely flexible, hypermobile joints throughout the body, not only in the feet.
Rigid Flatfoot Or Rigid Pes Planus
Unlike a flexible flatfoot, a rigid flatfoot is often the result of a significant problem affecting the structure or alignment of the bones that make up the foot's arch. Some common causes for rigid flatfeet include:
Congenital vertical talus. This is a problem in which an abnormal alignment of the foot bones eliminates the arch of the foot. In some cases, there is actually an abnormal reverse curve (a "rocker-bottom foot") in place of the normal arch. Congenital vertical talus is a rare condition that is present at birth and usually diagnosed by age 2 months. In about 50 percent of cases, it is related to one of the following problems: a genetic disorder, such as trisomy 18 or Down syndrome; a myelomeningocele; or exposure to some teratogen (an environmental agent that causes birth defects). In the remaining 50 percent of cases, the condition is considered to be idiopathic (arising spontaneously, with no known cause).
Tarsal coalition. ("peroneal spastic flatfoot") This is an inherited condition in which two or more of the foot bones are fused together, interfering with the flexibility of the foot and eliminating the normal arch. Tarsal coalition currently occurs in about 1 percent of the population. It is inherited as an autosomal dominant trait and commonly affects several generations of the same family.
Lateral subtalar dislocation. This is sometimes called an "acquired flatfoot," because it occurs in someone who originally had a normal foot arch. In a lateral subtalar dislocation, there is a simultaneous dislocation of the talus bone at two different joints within the arch of the foot. The dislocated talus slips out of place, drops downward and sideways, and collapses the arch. This condition is not inherited or present at birth; instead, it usually occurs suddenly because of a high-impact injury related to a fall from a height, a motor vehicle accident or participation in sports. Because of the high impact, 10 percent to 40 percent of cases also have an open wound in the area, and up to 45 percent are associated with fractured foot bones.
The majority of children and adults with flexible flatfeet never have symptoms; however, their toes may tend to point outward as they walk, a condition called out-toeing. A person who does develop symptoms usually complains of tired, aching feet, especially after periods of prolonged standing or walking.
Symptoms of rigid flatfoot vary depending on the cause of the foot problem:
Congenital vertical talus The foot of a newborn with congenital vertical talus typically has a convex "rocker-bottom" shape (like the bottom rails of a rocking chair), sometimes together with an actual "fold" at the midfoot. The rare patient who is diagnosed at an older age often has a "peg-leg" gait, poor balance and heavy calluses on the soles where the arch would normally be. If a child with congenital vertical talus has an underlying genetic disorder, additional symptoms are often seen in other parts of the body besides the feet.
Tarsal coalition Up to 22 percent of patients have no symptoms, and the condition is discovered only by chance when the foot is X-rayed for some other problem. When symptoms do occur, there is usually foot pain that begins at the outside rear of the foot, then spreads upward to the outer ankle and outside portion of the lower leg. Symptoms usually start during a child's teenage years and are aggravated by playing sports or walking on uneven ground. In some cases, the condition is discovered when the child is evaluated for unusually frequent ankle sprains.
Lateral subtalar dislocation Because this is often a traumatic, high-impact injury, the foot may be significantly swollen and deformed. There may also be an open wound with bruising and bleeding.
What Your Doctor Looks For
If your child has a flatfoot, the doctor will ask about any family history of flatfeet or inherited foot problems. In a patient of any age, the doctor will ask about occupation and recreational activities, orthopedic/podiatric history (especially foot trauma or foot surgery), and the type of shoes worn.
In older children and adults, the doctor will begin by reviewing symptoms, family history and orthopedic/podiatric history. Then, the doctor will examine the patient's shoes to check for signs of excessive wear. (Worn shoes can often provide valuable clues to gait problems and poor bone alignment.) Next, the doctor will ask the patient to walk barefooted to evaluate the arch area of the feet, to check for out-toeing, and to look for other signs of poor foot mechanics.
Finally, the doctor will perform a physical examination of the feet to evaluate foot flexibility and range of motion, and to palpate (feel) for any tenderness or bony abnormalities. Depending on the results of this physical examination, foot X-rays may be necessary.
In a young child with rigid flatfeet, and in an adult with acquired flatfeet due to trauma, X-rays are always an important part of the diagnostic process.
Although infants are usually born with flexible flatfeet, most develop normal arches sometime between the ages of 7 and 10. In the 15 percent to 20 percent of children whose flatfeet persist into adulthood, the condition is often inherited and lifelong. However, it may not cause symptoms.
A rigid flatfoot is a long-term condition, unless it is corrected with surgery or other therapy. (See Treatment.)
Since most cases of flatfeet are inherited, the condition is hard to prevent. Even when children with flexible flatfeet are treated with arch supports and corrective shoes, there is little evidence that this actually prevents them from becoming flatfooted adults.
Flexible Flatfoot - In most cases, doctors do not treat children with flexible flatfeet who are less than 3 years old. Even asymptomatic older children may not be treated, because their feet may still be growing, so an arch may eventually form.
There is little
conclusive evidence that corrective shoes and arch supports actually cure these
children.
If a child does develop symptoms and is older than age 3, the doctor may prescribe
a custom-made orthosis or corrective shoe. As an alternative, some doctors recommend
store-bought arch supports, since these can sometimes work as well as the more
expensive treatments in some individuals. In all of these conservative, nonsurgical
treatments, the goal is to relieve pain by supporting the arch and correcting
any imbalance in foot mechanics.
Surgery is rarely performed to treat a painful flexible flatfoot. It is only used as a last resort in patients with disabling pain, who have tried all other nonsurgical options.
Rigid Flatfoot - The treatment of a rigid flatfoot depends on its cause:
Congenital vertical talus Initially, some doctors try a period of serial casting (frequently changed casts that gradually reposition the foot), but this generally has a low success rate. Most patients ultimately need surgery to correct the problem.
Tarsal coalition Treatment depends on the age of the patient, extent of bone fusion and severity of symptoms. For milder cases, your doctor may recommend conservative nonsurgical treatment with shoe inserts, an orthosis, strapping or temporary immobilization in a cast. For more severe cases, surgery is necessary to relieve pain and improve the flexibility of the foot.
Lateral subtalar dislocation The goal of treatment is to slip the dislocated talus bone back into place as soon as possible. If there is no open wound, the doctor may be able to perform a procedure called a closed reduction under general anesthesia or spinal anesthesia. In this procedure, the doctor uses traction and countertraction to carefully maneuver the talus back into its normal position. Once this is accomplished, a short-leg cast must be worn for about four weeks to help stabilize the joint permanently. Only about 15 percent to 20 percent of patients with lateral subtalar dislocation must be treated with an open reduction, in which surgery is used to reposition the dislocated talus.
Call your doctor whenever you have foot pain, whether or not you have flatfeet. This is particularly important if your foot pain makes it difficult for you to walk.
If you are a parent, contact your family doctor if your child complains about foot pain, or if you are concerned that your child may be walking abnormally. Even if there are no foot symptoms, it is wise to check with your doctor periodically about your child's foot development, just to be sure that everything is progressing as expected.
Up to 20 percent of children with flexible flatfeet remain flatfooted as adults; however, most have no symptoms. If a child with flexible flatfeet begins to have foot pain, conservative treatment with shoe modifications can usually relieve the discomfort, although it may not permanently correct the foot arch.
For rigid flatfeet, the prognosis depends on the cause of the problem:
Congenital vertical talus Although surgery can usually correct the poor alignment of foot bones, many children with congenital vertical talus have underlying disorders that cause muscle weakness or other problems that interfere with full recovery.
Tarsal coalition When shoe modifications and orthoses are not effective, 20 percent to 30 percent of patients improve with casting. When surgery is necessary, the prognosis depends on many factors, including which bones are fused, the specific type of surgery and whether or not there is any evidence of arthritis in the foot joints. In one series of patients who were treated surgically, 80 percent had a "good" or "excellent" result. In a second series, 12 of 13 patients had "good" results, and the remaining patient had a "satisfactory" result.
subtalar dislocation With proper treatment, most patients recover without severe long-term complications or disability. In some cases, there is a residual stiffness in the area of the foot arch, but this does not necessarily cause pain or difficulty in walking. The risk for long-term complications is lowest in patients who have had at least three weeks of aggressive physical therapy after their cast is removed.