Flat Feet
Flat feet (Pes planus) are a common finding among the average population, regardless of age. Feet that pronate, or flatten excessively during gait can become very symptomatic, and cause severe deformity and arthritis. Just like many things in life, flat feet come in all kinds of shapes, and sizes. They often have planal dominance that will affect treatment, and dictate severity. Both kids and adults can suffer from painful flat feet. In kids, it is important to rule out a “tarsal coalition” – this is an abnormal connection of 2 bones in the hindfoot that occurred early in skeletal development.
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Doctor Adams is a Fellowship Trained Foot and Ankle Surgeon. He completed his Fellowship at American Health Network in Indianapolis. This is one of the most respected and longest running Fellowships in the country.
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If you are searching for a Foot and Ankle Surgeon who can provide you with pain relief associated with your flatfoot deformity, Central Indiana Foot and Ankle Surgeon Dr. Wil Adams will be happy to consult with you.
If you have questions or concerns, please feel free to call Dr. Adams at (317) 477-6683, or schedule a consultation online.
Learn more about Dr. Adams
Dr. Adams is a born and raised Hoosier. He attended Indiana University-Bloomington where he met his wife Allison. He got degrees in Nutrition Science, Biology and Chemistry. Dr. Adams then got his doctorate from Kent State College of Podiatric Medicine where he was a Dean’s List student. He then came back to Indianapolis to do his residency surgical training and was Chief resident. He stayed in Indianapolis and completed a specialty Fellowship focusing on Adult and Pediatric Reconstruction. During his Fellowship Dr. Adams helped launch the first foot and ankle dedicated surgical practice at Hancock Orthopedics, and has been employed there since.
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Dr. Adams enjoys teaching as he helps educate and train the surgical residents at Community Health Network, and the Fellows at American Health Network. He actively participates in research and editing for national peer reviewed journals.
He is also a consultant for orthopedic device companies where he is afforded the opportunity to help train and design with other surgeons across the country.
Dr. Adams has special interests in the following areas:
Arthroscopic joint surgery
Minimally invasive calcaneal fracture repair
Flat foot reconstruction, adult and pediatric
Vitamin D and its correlation with bone healing
Cartilage restoration for the ankle joint
Regenerative medicine
5th Metatarsal fractures
Non-union revision surgery
Dr. Adams is a father of two and resides with his family in Fishers. He enjoys the short commute to Hancock Health in Greenfield.
William J.E. Adams, DPM CV (pdf)
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Which comes first – the chicken or the egg? Posterior tibial tendon dysfunction kind of embodies this phrase. Does the PT tendon start to weaken allowing a collapsed arch? Or does a flat foot predispose people to PT tendon dysfunction? I personally feel that it is the latter. People, the vast majority of the time are born with the genetic blueprints to develop flat feet during skeletal maturation. Over time this faulty architecture takes it toll on the supporting soft tissues such as the spring ligament and the PT tendon. If proper support and treatment is not sought out the end result is painful Posterior Tibial Tendon Dysfunction (PTTD). There are stages of degeneration noted with PTTD. In early stages treatment options are more vast and successful. In the late stages of PTTD there are far fewer options available, and either robust bracing, or surgical correction is necessary to prevent total arch collapse and painful arthritis within the ankle joint.
Yes – PTTD is a degenerative condition. It cannot be reversed. With excellent care it can be very well managed, and even “corrected”.
Yes – arch supports can help control excessive motion (pronation), and provide support to the arch, therefore decreasing tension on the soft tissues/ligament. When left untreated patients with “fallen arches/PTTD” develop Spring ligament tears. The spring ligament is a very thick band of connective tissue underneath the talus bone that supports the arch, and acts as a buttress during weight bearing activities. When the spring ligament tears and becomes insufficient, arch collapse has taken place.
It does not help. There are people with PTTD that are ideal body weight yet still struggle with flat foot pain and degeneration. However, your feet are your foundation and adding extra weight along the ligaments and tendons that support your arch only exacerbates the condition.
No – shoes are kind of like gloves, and every person seems to do best in what fits their feet best. However, generally speaking people with flatfeet (pes planus) need shoes where the instep/arch of the shoe is built up and has a synthetic “bridge” present. Shoe companies often refer to these shoe models as motion control, stability shoes, and similar synonyms. The shoe industry likes to use the term “over-pronation” to describe shoes made for people with flat feet.
Both prescription and non-prescription ankle braces are great options for patients with painful arch collapse. These braces can be custom made from a cast of your foot, and they can also be “off the shelf/non-custom”. Most insurance companies do pay for bracing.
Surgery is often very effective to fix a painful flatfoot. There are multiple ways to perform the surgery. Procedure selection is based upon the patients wishes, clinical needs, and based on x-rays.
It depends on the procedures you and your surgeon choose. Generally speaking the non weight bearing period after surgery lasts 6-8 weeks – contingent upon bone healing. Many patients will be able to bear weight at week 6 in a walking boot. We hope to get patients back into a sneaker at 10 weeks, and start physical therapy. (Please realize all patients heal at different speeds, and these timeframes can vary substantially)
Flat feet can bother both children and adults alike. The severity of the condition often dictates when the condition manifests. In instances where a flat foot is painful during childhood it is because the condition is more severe.
The condition is best diagnosed through a thorough physical exam, and x-rays. Diagnosing the deformity is actually more accurate with a xray, rather than an MRI as x-rays are taken while the patient is bearing weight – which provides a more accurate depiction of the bony architecture of the foot. While this is true – sometimes a MRI is still ordered to rule out a tarsal coalition.
Our first treatment option for symptomatic flat feet (pes planus) in children is always to utilize orthotics (shoe insert). This can help support the arch and take pressure of ligaments and tendons that are responsible for supporting the foot. This insert does not necessarily need to be an expensive custom device.
Children often complain of pain first by suggesting their “feet hurt”, or they are “tired of walking”. Occasionally, this is simply due to a long day of activities and can be associated with growing pains. When the complaint becomes recurrent this is when we recommend evaluation by a specialist.
When conservative care fails to allow resolution of symptoms to an acceptable level surgical intervention is appropriate.
The surgical options for pediatric flat feet are similar and also dissimilar to the procedures utilized to correct adult flat feet. Both the Evans and Cotton osteotomies are procedures routinely utilized due to their utility, and predictability. In more mild cases soft tissue procedures, and an arthroeresis procedure may be appropriate. These decisions are carefully made with the patient, surgeon and parent.
Accessory Navicular bones can come in three variations. The most basic, and common type of Accessory navicular is where a small piece of bone that lies adjacent to the navicular bone is embedded within the Posterior tibialis muscle tendon at it’s attachment site. Due to overuse, trauma, flat feet, and other causes this bone and the tendon interface can become inflamed. When the process initiates, and fails to get better is the definition of “Accessory Navicular Syndrome”.
Yes – it’s possible to live many years with an accessory navicular bone never being aware you have one. Then one day a traumatic event such as an ankle sprain, or an awkward step can cause the PT tendon to pull on the accessory bone causing the interface between the accessory bone and the tendon to become very aggravated. On occasion they do need to be surgically excised.
No. There are instances where people that have accessory navicular syndrome also have flatfeet. But there are also many individuals that have accessory naviculars that have fairly neutral or rectus foot types.
No – not necessarily. The only time surgery is necessary is when a patient has failed multiple attempts and different types of conservative care to try and resolve the issue.
The techniques utilized to “fix” flat feet can be subdivided into 3 categories/procedure types that allow correction;
Fusion (arthrodesis)
Osteotomy (corrective bone cut)
Soft tissue augmentation (tendons and ligaments), or lastly, perhaps a mixture of all these (this is common practice).
Within the first two categories there are important differences that need to be considered. The nomenclature is important ; referring to whether the joint is involved in the bony procedures, or not. This in medical terms is coined extra-articular vs intra-articular.
Extra = outside Intra = inside articular = joint
In layman’s terms this means a procedure is performed inside, or outside the joint. For example, a fusion/arthrodesis or joint replacement procedure is a surgery used that addresses pain, but destroys the joint, and is considered an “intra-articular” procedure. When people have end stage arthritis, or severe deformities, it is okay to “sacrifice” the joint to allow for correction, and pain relief. An ankle, or knee replacement is an example of an intra-articular surgery. An ankle fusion/arthrodesis is also an intra-articular procedure. For obvious reasons, these procedures are not always preferred for every demographic.
When kids, or individuals with healthy joints simply need realignment for deformity correction, extra-articular, or procedures that “spare” the joint are preferred. These are often mixed with soft tissue augmentation procedures to gain maximal correction.
This is an osteotomy created by the late Dr. Dilwyn Evans in the 1960s. It essentially involves cutting with a small surgical saw the outside of the heel bone. Once the cut is made, a widening device is inserted into the surgical site, and used to open the osteotomy, therefor elongating the calcaneus bone. Once the desired correction is achieved (we typically aim to widen or elongate by 6-12mm depending on severity of deformity and patient size), a space filling device (an implant) is inserted into the void created. This allows that lengthening that was created to be preserved, and maintained indefinitely. Surgeons often choose to use porous metallic (titanium) wedges vs bone (typically cadaver bone, or synthetic material) wedges. The idea is that your own calcaneus bone incorporates into this implant/graft. Once the surgical site is healed, the correction is maintained, and the arch has effectively been restored, or created. This is a permanent procedure.
Similar to the Evans osteotomy, the Cotton osteotomy is named after its doctor/surgeon inventor. It is a procedure that is very commonly utilized at the same time as an Evans. The procedure is performed in the medial cuneiform bone. A small saw is used to make a cut into the cuneiform bone, again, similarly as the Evans, a distraction device is then introduced to “open” or distract the osteotomy site. This effectively lengthens the medial column of the foot. It pitches the bones preceding the great toe towards the floor, helping create an arch. With x-ray guidance in the operating room the proper amount of correction is then chosen, just like an Evans. Most commonly a 5-8mm wedge is utilized. This wedge implant is placed into the osteotomy to maintain correction. It is left in the site permanently. It is often fixated, or fastened in place with a small titanium plate, or staple. This procedure provides a lot of correction – however, it is not always needed. The surgeons goal is to provide good correction, and prevent instances where the hardware or the wedge would need to be removed. The most common reason for introduction of the Cotton Osteotomy when treating flat feet both in adults, and pediatric patients is to both help restore the medial longitudinal arch of the foot, but also to prevent a forefoot varus/supinatus deformity. The Evans Osteotomy has the ability to create a forefoot deformity in some patients. If this deformity is not identified intra-operatively by the surgeon, patients are left with the inability for the great toe joint to properly purchase the ground during gait. This causes the patient to manipulate their foot inefficiently through the hindfoot, or ankle joints.
This procedure is sometimes also known as a medial calcaneal displacement osteotomy, or a Koutsogiannis osteotomy. The procedure originated in the 1970’s. It is performed by using a sagittal saw to make an oblique osteotomy through the back 1/3 of the calcaneus (heel bone). It is most often done through an oblique skin incision at the outside/lateral aspect of the heel, just in front of the Achilles tendon. Once the cut is completed, the portion of the heel bone that has been cut, is then shifted medially, or closer towards umbilicus. It is then traditionally fixated in the corrected position with 1-2 screws. These screws typically do not need to be removed even once the bone is fully healed. They are placed through a small incision at the back of the heel with x-ray guidance. By shifting the heel bone medially, this alters the mechanics of the Achilles tendon, and takes the heel bone out of an everted position.
This procedure has also been around for a long time, and is executed with varying techniques in terms of reattaching the tendon. The basic concept revolves around taking the tendon that flexes the lesser toes, and giving it a new attachment site/insertion. This is done because oftentimes a flat foot over the years has caused significant disease to the PT (posterior tibial) tendon. It gets overworked, and weakened. Sometimes even torn, and ruptured in more advanced cases of
PTTD. When the PT tendon that supports the arch, and inverts the hindfoot becomes grossly insufficient, we want to reinforce it. We do this by transferring the FDL tendon to a new attachment site at the navicular bone. The most effective way to execute this procedure is by drilling a small hole in the navicular bone. We drill that hole, then take suture and attach it to the FDL tendon. We then properly tension the FDL tendon at its new navicular insertion site/hole, and make it permanent by using an interference screw to hold it in place. Patients often ask if this will hurt the functionality of their lesser toes, and in short, the answer is no. Adequate flexion strength remains due to the short flexors, and the Master Knot of Henry. It is important to understand this procedure in isolation is not robust enough to address a flatfoot. The procedure is meant to be an ancillary procedure, used in conjunction with other more powerful procedures.
Arguably the most important ligament in the foot next to the Lisfranc ligament. It is a powerful support, or strut to the medial arch of the foot. It supports the talonavicular joint and prevents collapse of the arch. It is an extremely thick ligament that takes years of abuse, or significant trauma to cause tearing, or rupture. When this ligament becomes diseased it is vital to intervene as over time an unaddressed disease process will wreak havoc on the medial column of the foot. This ligament tearing due to overuse and planus deformities is what is part of the “fallen arch” syndrome. The common technique employed to repair this ligament is to bypass it altogether by fusing, or performing an arthrodesis to the talonavicular joint, or by repairing it directly by using synthetic suture materials. There are orthopedic companies now that provide very strong suture devices that may be employed to repair this extremely important ligament. Not all surgeons perform this procedure as there is some technical skill required with it.
