Adult Onset Flat Feet Stage 2 - Royal United Hospital

Recovery

It often takes 12 months for all swelling to resolve and so

minor swelling late in the day is not unusual and should not

be a cause for concern.

These notes are intended as a guide only and some of the

details may according to your individual circumstances.

Information for Patients

Adult Onset

Flat Feet

Stage 2

Advice Sheet

For more information

Contact the Orthopaedic Directorate

Mr Derek Robinson

Tel: 01225 825338

Fax: 01225 825526

BSc, MB ChB, FRCS (Trauma & Orthopaedics)

Consultant Orthopaedic Surgeon

Foot and Ankle Specialist

Date of publication: February 2010

Ref: RUH ORT/012

? Royal United Hospital Bath NHS Trust

Walking

Most people's feet have a space on the inner side where the

bottom of the foot is off the ground (the "arch" of the foot). The

height of this arch varies a lot from one person to another. People

who have a low arch or no arch at all are said to have flat feet.

Many people have a low arch and have had it since childhood. If

you have had a normally arched foot that becomes flat in middle

age it is termed adult onset flat foot.

Cause

There are several causes of adult onset flat foot but the most

common is Tibialis Posterior Tendon Dysfunction. Tibialis Posterior

is a large muscle that runs from the calf into the foot behind the

inner aspect of the ankle (medial malleolus). Its function is to turn

the foot inwards, support the arch and help to initiate tip-toe

standing.

The tendon itself may become inflamed initially and so may not

function properly. As the inflammation continues it causes the

tendon to degenerate and stretch and it will eventually rupture.

Therefore the ability of the tendon to maintain the arch is lost and

the arch will collapse.

A physiotherapist will show you how to use crutches or a frame. It

is necessary for you to walk without taking weight on your foot for 2

weeks. After 2 weeks a full plaster will be applied and you can take

some weight on the foot for a further 6 week period. After 8 weeks

a removable walking plaster is applied in which you can fully

weight-bear for a further 4 weeks. It will be necessary for you to

wear this for a further 4 weeks during the day.

Follow-Up

You will be seen after approximately 2 weeks when the dressings

and stitches will be removed. At this stage a removable walking

plaster will be made that will give your foot support during the day.

It is not necessary to wear this at night. You will be seen again at 6

weeks and if all is well you will be referred to the physiotherapists

and you can discard the plaster.

Driving

You should not drive a manual car for 12 weeks following surgery.

After this you should start gradually, to see if you are comfortable.

It normally takes a few days to feel confident. If you have an

automatic car and have only had the left foot operated upon then

you may drive after 2 weeks.

Symptoms

Work

There are several stages of the disease and if the condition is not

treated promptly it will tend to progress and become more severe.

The onset of symptoms is usually gradual but it can follow an injury

and be rapid. Initially pain and possibly swelling will be present on

the inner side of the ankle just below the ankle bone (medial

If you have an office based job then it may be possible for you to

return after 2 weeks however it is more advisable to return after 812 weeks. If you have a more physical job then it may take 16-20

weeks.

? Anaesthetic

Surgery is usually performed under general anaesthetic and

so you are asleep. This is incredibly safe but there are

exceptional circumstances where an adverse reaction may

occur which is dangerous, even life threatening. Certain

patients have many medical problems which may increase

the risk and so it may be necessary to be seen by an

anaesthetist to further discuss the issues prior to being

brought into hospital. All patients will be checked for fitness

for surgery in our specialist pre-operative assessment clinic.

Discharge Advice

Dressings

Your leg has been placed in a plaster backslab. This should not be

changed until you are seen at your first follow-up appointment after

2 weeks. The plaster must be kept clean and dry.

Elevation

malleolus). During this phase the foot may keep its normal shape

and the arch may not drop. It is due to inflammation around the

tendon. It is known as stage 1 disease. If the condition is not

treated the tendon will deteriorate and stretch. The arch will fall and

the heel will start to move outwards. Because of this pain will often

start to be felt on the outer side of the ankle as the tissues on the

outer side of the ankle become trapped between the heel and the

outer ankle bone (fibula). Initially the joints at the back of the foot

remain supple and it is possible for your doctor to correct the

position of the foot, this is known as stage 2 disease. If the

condition remains untreated the joints at the back of the foot

develop arthritis due to the abnormal position that they are in and

the joints become stiff. If this occurs it is not possible for your

doctor to correct the position of the foot in the clinic and this is

known as stage 3 disease.

Treatment Options

For stage 2 disease (tendon stretched or ruptured with heel turned

out but joints mobile) it may be possible to control the symptoms

with insoles to realign the heel but it is usually necessary to

perform surgery.

It is very important that you rest as much as possible and keep

your foot elevated. Try to avoid letting it hang down when sitting as

this will lead to swelling and pain. This is most apparent within the

first 2 weeks but swelling may occur for up to 6 months after

surgery, especially after sitting or standing for long periods. In bed,

put the foot on a pillow.

Operation Details

Analgesia

Two incisions are necessary. A 10cm incision that curves around

the outer side of the heel is made and allows the heel bone to be

divided. The back portion of the heel bone is then moved about

1cm inwards and fixed with a screw. This will realign the heel and

remove the pressure from the tissues on the outer side of the

ankle.

You will receive a prescription for pain medication on discharge.

Pain is often due to swelling and this is eased by rest and elevation

of the foot.

Surgery is performed under general anaesthetic usually as an in

patient. The stay is usually 1-2 nights. The procedure takes about

2 hours. The aim of surgery is to realign the heel and replace the

function of the tibialis posterior tendon which is not working.

A 12cm incision is made on the inner side of the foot and ankle.

This runs from the ankle bone (medial malleolus) down into the

arch of the foot. A tendon which runs next to the tibialis posterior

tendon which normally helps to bend the lesser toes down is then

identified (flexor digitorum longus). This tendon is divided in the

arch of the foot and used to replace the function of the tibialis

posterior tendon. This is done by making a hole in the bone where

the tibialis posterior tendon normally inserts and passing the new

tendon through it and stitching it in place. It is still possible to bend

the lesser toes down as there is another muscle which acts in this

way. The tissues are stitched and a below knee half plaster cast is

then applied.

? Ongoing deformity

The operation is not able to fully correct the shape of the foot but

there should be an improvement. It may be necessary to wear

insoles after the procedure.

? Prominent Screw

A screw is placed from the back of the heel. Occasionally you

can feel this and it may cause irritation. If this occurs it can be

removed

General considerations

Risks of Surgery

? Infection

This is always a risk when a cut is made in the skin. Every

possible precaution will be taken and intravenous antibiotics

will be given at the start of the operation and for a day

afterwards. In the vast majority of cases it will be eradicated

with a course of antibiotics.

? Nerve injury

Nerves run behind the tibialis posterior tendon. Every effort is

made to protect them throughout the procedure but very

rarely they may be injured. Nerve damage would lead to an

area of numbness on the sole of the foot. This is usually

temporary but may be permanent.

? Scar sensitivity

This is helped by massaging the scar regularly to de-sensitise

it.

? Swelling

Feet tend to swell after surgery. Excessive swelling causes

pain and increases the risk of complications. The best way to

prevent this is to elevate the feet as much as possible.

? Smoking

Smoking leads to a huge increase in surgical risk, particularly

affecting wound healing and infection (16 times higher). It is

strongly advised that you stop smoking prior to any surgery.

? Blood Clot

A blood clot in the deep veins of the leg (deep vein

thrombosis DVT) may occur following foot and ankle surgery

but is rare. There are many factors to take into account when

considering the level of risk and it may be necessary to give

injections or take medication to reduce the risk. There is a

very small chance that the clot may break off and travel to the

lungs (pulmonary embolus PE) and this can be dangerous,

even life threatening. If you feel that the calf has become

swollen and painful or you become breathless then seek

medical attention immediately.

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