{"product_id":"understanding-adult-flatfoot-a-complete-guide-to-diagnosis-and-treatment","title":"Understanding Adult Flatfoot: A Complete Guide to Diagnosis and Treatment","description":"\u003cp\u003eAdult flatfoot is far more than a simple \"fallen arch\" — it is a complex condition involving three distinct levels of the foot (the hindfoot, ankle, and midfoot), each requiring careful evaluation before treatment. This article, based on a peer-reviewed surgical research paper by Dr. E. Toullec, explains how flatfoot develops, how doctors diagnose it using physical exams and imaging, and reviews both non-surgical and surgical treatment options with specific measurements and success criteria. Importantly, the research emphasizes that adult flatfoot is frequently diagnosed and treated too late, leading to complicated ankle problems that are much harder to manage.\u003c\/p\u003e\n\n\u003ch1\u003eUnderstanding Adult Flatfoot: A Complete Guide to Diagnosis and Treatment\u003c\/h1\u003e\n\n\u003ch2\u003eTable of Contents\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003e\u003ca href=\"#ddn-key-points\"\u003eKey Points\u003c\/a\u003e\u003c\/li\u003e\n\n  \u003cli\u003e\u003ca href=\"#introduction\"\u003eWhat Is Adult Flatfoot?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#why-flatfoot-develops\"\u003eWhy Does Adult Flatfoot Develop?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#symptoms\"\u003eRecognizing the Symptoms\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#clinical-exam\"\u003eHow Doctors Examine the Foot\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#imaging\"\u003eImaging Studies: X-rays, Ultrasound, MRI, and CT\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#classification\"\u003eTypes and Classifications of Flatfoot\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#medical-treatment\"\u003eNon-Surgical Treatment\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#hindfoot-surgery\"\u003eSurgical Treatment: Hindfoot Procedures\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#ankle-surgery\"\u003eSurgical Treatment: Ankle Procedures\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#midfoot-surgery\"\u003eSurgical Treatment: Midfoot Procedures\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#implications\"\u003eWhat This Means for Patients\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#ddn-faq\"\u003eFrequently Asked Questions\u003c\/a\u003e\u003c\/li\u003e\n\u003cli\u003e\u003ca href=\"#source\"\u003eSource Information\u003c\/a\u003e\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003c!-- ddn:keypoints:start --\u003e\n\u003ch2 id=\"ddn-key-points\"\u003eKey Points\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003eAdult flatfoot involves hindfoot, ankle, and midfoot, not just the arch.\u003c\/li\u003e\n\u003cli\u003eOnly symptomatic flatfoot requires treatment; many people have painless flat feet.\u003c\/li\u003e\n\u003cli\u003eWeight-bearing X-rays are essential; some deformities disappear when lying down.\u003c\/li\u003e\n\u003cli\u003eNon-surgical care includes insoles, physiotherapy, and up to 6 weeks of casting.\u003c\/li\u003e\n\u003cli\u003eLate treatment raises risk of ankle arthritis, making surgery more complex.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003c!-- ddn:keypoints:end --\u003e\n\n\n\u003ch2 id=\"introduction\"\u003eWhat Is Adult Flatfoot?\u003c\/h2\u003e\n\n\u003cp\u003eAdult flatfoot is defined by a \u003cstrong\u003eflattening of the medial (inner) arch of the foot when standing\u003c\/strong\u003e (weight-bearing), combined with a lack of propulsive gait, meaning the foot cannot push off the ground effectively during walking. It is not a single problem but a \u003cem\u003esyndrome\u003c\/em\u003e — a combination of multiple static and dynamic deformities that work together.\u003c\/p\u003e\n\n\u003cp\u003eThe key to understanding flatfoot is recognizing that all forms share one common failure: the \u003cstrong\u003efoot fails to \"lock\" during gait\u003c\/strong\u003e. Normally, the foot transforms from a flexible shock absorber to a rigid lever when pushing off. When this locking mechanism fails, the arch collapses and deformities progress.\u003c\/p\u003e\n\n\u003cp\u003eThe article highlights \u003cstrong\u003ethree anatomical levels\u003c\/strong\u003e that can be involved:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003eThe \u003cstrong\u003etalonavicular joint\u003c\/strong\u003e (where the ankle bone meets the navicular bone in the midfoot)\u003c\/li\u003e\n  \u003cli\u003eThe \u003cstrong\u003etibiotarsal joint\u003c\/strong\u003e (the main ankle joint)\u003c\/li\u003e\n  \u003cli\u003eThe \u003cstrong\u003emidfoot joints\u003c\/strong\u003e (including the Lisfranc and Chopart joint lines)\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eThe \u003cstrong\u003esubtalar joint\u003c\/strong\u003e (the joint below the ankle that allows side-to-side foot movement) is also damaged as a result of the rotational deformities that occur in flatfoot. Understanding which of these levels is primarily affected is crucial because treatment must target the correct location.\u003c\/p\u003e\n\n\u003ch2 id=\"why-flatfoot-develops\"\u003eWhy Does Adult Flatfoot Develop?\u003c\/h2\u003e\n\n\u003cp\u003eFlatfoot develops when the structures that support the arch become strained or fail. The research identifies \u003cstrong\u003ethree key anatomical zones\u003c\/strong\u003e where locking failure can occur:\u003c\/p\u003e\n\n\u003ch3\u003e1. The Talocalcaneonavicular Joint (the \"Coxa Pedis\")\u003c\/h3\u003e\n\u003cp\u003eThis joint sits at the summit of the medial arch. During standing and walking, it bears pressure from the talar head (the top ankle bone), which increases as the tibia (shin bone) advances forward over the foot. A critical support structure called the \u003cstrong\u003emid-plantar tendon-ligament sling\u003c\/strong\u003e — made up of the calcaneonavicular (or \"spring\") ligament and the posterior tibial tendon — provides elastic support to this area. Progressive strain on this sling is the \u003cstrong\u003emost common cause of flatfoot\u003c\/strong\u003e, leading to midfoot abduction (the front of the foot turning outward).\u003c\/p\u003e\n\n\u003cp\u003eInterestingly, the article references a specific anatomical variation: researcher Bonnel described a \u003cstrong\u003etype-III morphotype\u003c\/strong\u003e in which the talus bone is longer than the calcaneus (heel bone), causing greater pressure on these supporting tendons and ligaments.\u003c\/p\u003e\n\n\u003ch3\u003e2. The Medial Collateral Ligament (MCL) of the Ankle\u003c\/h3\u003e\n\u003cp\u003eWhen the heel strikes the ground, the \u003cstrong\u003emedial collateral ligament\u003c\/strong\u003e (the ligament on the inner side of the ankle) is subjected to stress because the calcaneus and tibia are not naturally aligned in a straight line. If this ligament becomes stretched out (distended), it causes \u003cstrong\u003etibiotarsal valgus\u003c\/strong\u003e — the ankle tilts inward — and weight-bearing shifts progressively toward the inner edge of the foot, putting additional strain on the joints further along the foot.\u003c\/p\u003e\n\n\u003ch3\u003e3. The Midfoot and the Windlass Mechanism\u003c\/h3\u003e\n\u003cp\u003eRaising the heel during walking automatically causes the toes to bend upward (dorsiflexion), which creates tension in the plantar muscles and the plantar fascia (the thick band of tissue across the bottom of the foot). This is known as the \u003cstrong\u003e\"windlass mechanism\"\u003c\/strong\u003e and it locks the midfoot joints, creating a rigid lever for push-off. If this locking fails — for example, due to \u003cstrong\u003efirst-ray hypermobility\u003c\/strong\u003e (excessive looseness of the big toe metatarsal bone) — the first metatarsal elevates during weight acceptance, leading to a defect during single-leg stance and toe-off.\u003c\/p\u003e\n\n\u003cp\u003eThe article notes that \u003cstrong\u003etrauma can also play a role\u003c\/strong\u003e. Long-standing injuries, such as ankle sprains that involved the medial side of the ankle or midfoot, should be investigated in any flatfoot assessment because they can contribute to the deformity.\u003c\/p\u003e\n\n\u003cp\u003eIn summary, a proper flatfoot evaluation must examine all three of these levels \u003cem\u003eplus\u003c\/em\u003e the subtalar joint, which experiences abnormal rotational stress in flatfoot.\u003c\/p\u003e\n\n\u003ch2 id=\"symptoms\"\u003eRecognizing the Symptoms\u003c\/h2\u003e\n\n\u003cp\u003eAn important point from the research: \u003cstrong\u003eflatfoot is only considered pathological (a disease) when it causes symptoms\u003c\/strong\u003e. Many people have flat feet without pain.\u003c\/p\u003e\n\n\u003ch3\u003eMedial (Inner) Pain\u003c\/h3\u003e\n\u003cp\u003ePain is generally located in the \u003cstrong\u003emedial part of the hindfoot\u003c\/strong\u003e (the inner side of the back of the foot), along the path of the posterior tibial tendon. There may be swelling (effusion) within the tendon sheath. Pain that is located deeper and on the sole of the foot may indicate a \u003cstrong\u003espring ligament lesion\u003c\/strong\u003e. However, the article warns that similar pain can also be caused by other conditions, including:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eTalocalcaneal synostosis coalition\u003c\/strong\u003e (an abnormal bone connection between the talus and calcaneus)\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eOsteoarthritis\u003c\/strong\u003e (wear-and-tear arthritis) in the talonavicular, subtalar, or mediotarsal joints\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003ch3\u003eLateral (Outer) Pain\u003c\/h3\u003e\n\u003cp\u003ePain on the outside of the foot can result from several impingement (pinching) problems:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eFibulocalcaneal impingement\u003c\/strong\u003e — pinching between the fibula (outer lower leg bone) and calcaneus, occurring in severe ankle valgus\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eCalcaneocuboid impingement\u003c\/strong\u003e — pinching between the heel bone and the cuboid bone in the presence of severe forefoot abduction\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eImpingement between the lateral tubercle of the talus\u003c\/strong\u003e and the dorsal angle of Gissane (a specific landmark on the anterior apophysis of the calcaneus), caused by rotation and slippage of the talus\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003ch2 id=\"clinical-exam\"\u003eHow Doctors Examine the Foot\u003c\/h2\u003e\n\n\u003cp\u003eThe clinical examination has two main goals: determine the characteristics of the deformity and determine \u003cstrong\u003ewhether the deformities are reducible\u003c\/strong\u003e (correctable by manual manipulation) or fixed. Doctors also assess range of motion and screen for joint stiffness, which could point to synostosis coalition or osteoarthritis.\u003c\/p\u003e\n\n\u003ch3\u003eHindfoot Examination\u003c\/h3\u003e\n\n\u003cp\u003eThe \u003cstrong\u003ebipedal tiptoe test\u003c\/strong\u003e (rising onto both toes) normally causes the hindfoot to invert (turn inward). If inversion is lost or the foot actually everts (turns outward), this signals dysfunction of the subtalar and Chopart joints (either stiffening or excessive looseness) and\/or weakness of the posterior tibial muscle.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAbduction\u003c\/strong\u003e (outward turning of the forefoot) is assessed with the patient standing while the examiner observes from behind, looking for the \u003cstrong\u003e\"too-many-toes sign\"\u003c\/strong\u003e — more toes visible from behind than normal, indicating the forefoot is drifting outward. Abduction can also be observed in a lying position by examining the sole of the foot for a break in the lateral (outer) edge. Hallux valgus (bunions) is often associated with flatfoot.\u003c\/p\u003e\n\n\u003cp\u003eThe \u003cstrong\u003eposterior tibial tendon\u003c\/strong\u003e is tested by asking the patient to invert the foot against resistance while starting from an everted (turned-out) position. The doctor notes any resulting pain and loss of muscle force. A complete motor assessment of all foot muscles is performed to rule out a neurologic cause.\u003c\/p\u003e\n\n\u003cp\u003eThe \u003cstrong\u003eunipedal tiptoe test\u003c\/strong\u003e (single-leg toe raise) is a powerful diagnostic tool that assesses both the posterior tibial muscle and the spring ligament. The results are interpreted as follows:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003eIf the foot moves into eversion during single-leg toe raise (or the heel fails to rise), even though the patient can perform a normal bipedal tiptoe, the \u003cstrong\u003eposterior tibial tendon is involved\u003c\/strong\u003e.\u003c\/li\u003e\n  \u003cli\u003eReduced active inversion in this test may suggest a \u003cstrong\u003espring ligament lesion\u003c\/strong\u003e.\u003c\/li\u003e\n  \u003cli\u003ePain along the posterior tibial tendon when repeating the test is a sign of \u003cstrong\u003etendinitis\u003c\/strong\u003e (tendon inflammation).\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eThe article also warns that in some cases, \u003cstrong\u003etendon-muscle retraction\u003c\/strong\u003e (tightness) may hold the deformity in place even when not weight-bearing. The calf muscle (sural triceps) can fix the valgus position, and the fibular muscles can fix abduction. To determine whether there is an underlying joint stiffness, the doctor examines the ankle in plantar flexion (pointed down), which relaxes these tight tendons.\u003c\/p\u003e\n\n\u003ch3\u003eTibiotalar (Ankle) Joint Examination\u003c\/h3\u003e\n\n\u003cp\u003eDoctors assess ankle dorsiflexion (the ability to bend the foot upward) with the hindfoot valgus corrected, first with the knee in extension and then with the knee flexed. This is called the \u003cstrong\u003eSilfverskiold test\u003c\/strong\u003e, and it helps identify gastrocnemial retraction (tightness of the gastrocnemius calf muscle).\u003c\/p\u003e\n\n\u003cp\u003eHindfoot valgus when standing can be due to \u003cstrong\u003emedial laxity of the ankle\u003c\/strong\u003e (loose ligaments on the inner ankle) or to \u003cstrong\u003eforefoot supination\u003c\/strong\u003e (the front of the foot rolling outward). Medial ankle laxity is not always easy to detect. Forefoot supination is analyzed with the patient lying on their back with the hindfoot valgus corrected. The \u003cstrong\u003ereverse Coleman test\u003c\/strong\u003e uses a 2-cm block placed under the first metatarsal head to demonstrate whether hindfoot valgus corrects when the first ray is supported.\u003c\/p\u003e\n\n\u003ch3\u003eMidfoot Examination\u003c\/h3\u003e\n\n\u003cp\u003eThree elements are explored in the midfoot: supination, first-ray hypermobility, and osteoarthritic stiffness.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eSupination:\u003c\/strong\u003e The \u003cstrong\u003eHintermann test\u003c\/strong\u003e determines whether supination is fixed. The doctor externally rotates the leg while the foot is weight-bearing. If the first metatarsal head rises, the supination is fixed; if not, it is reducible.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFirst-ray hypermobility:\u003c\/strong\u003e The doctor holds the first ray (big toe metatarsal) between thumb and index finger and moves it up and down while stabilizing the other metatarsals. Signs that suggest hypermobility include a \u003cstrong\u003eplantar corn under the second metatarsal head\u003c\/strong\u003e (due to abnormal weight transfer) and gait that shows first-ray elevation during forefoot weight acceptance. The \u003cstrong\u003eJack test\u003c\/strong\u003e (passive hallux dorsiflexion — pushing the big toe upward) explores whether the medial arch rises. Normally, dorsiflexing the big toe tightens the plantar fascia and the flexor hallucis longus tendon, which stabilizes and lowers the medial arch. In first-ray hypermobility, the foot does not arch, and the first metatarsophalangeal joint shows excessive dorsiflexion with a \"soft stop\" (a mushy endpoint rather than a firm one), indicating a plantar muscle locking defect.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eOsteoarthritic stiffness:\u003c\/strong\u003e This is indicated by dorsal (top-of-foot) swelling due to osteophytosis (bone spurs) and impaired motion in the Lisfranc joint line.\u003c\/p\u003e\n\n\u003ch2 id=\"imaging\"\u003eImaging Studies: X-rays, Ultrasound, MRI, and CT\u003c\/h2\u003e\n\n\u003ch3\u003eX-rays (Weight-Bearing)\u003c\/h3\u003e\n\n\u003cp\u003eX-rays are the first-line imaging assessment and must always be taken \u003cstrong\u003ein weight-bearing position\u003c\/strong\u003e, because some flatfoot deformities completely disappear when the patient is not standing. The standard set includes \u003cstrong\u003ethree views\u003c\/strong\u003e:\u003c\/p\u003e\n\n\u003col\u003e\n  \u003cli\u003e\n\u003cstrong\u003eDorsoplantar view\u003c\/strong\u003e (top-down) — used to measure abduction. Doctors measure the angle between the talus and the first or second metatarsal, the amount of talar head uncovering, and the talocalcaneal divergence angle, which shows the degree of talar rotation.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eLateral view\u003c\/strong\u003e (from the side, patient standing) — used to assess flattening. Key measurements include the angle between the talus and first metatarsal (\u003cstrong\u003enormal = 0°\u003c\/strong\u003e), the calcaneal slope (\u003cstrong\u003enormal = 15–20°\u003c\/strong\u003e), and the talocalcaneal divergence angle (\u003cstrong\u003enormal = 25–35°\u003c\/strong\u003e). It is essential that the first ray is weight-bearing for this view; otherwise the lateral view may appear falsely normal. This view identifies where the arch is breaking, dorsal impingement in osteoarthritis, and \"plantar gap\" in hypermobility — best detected by placing a block under the first metatarsal. Tibiotalar equinus (a downward-pointing ankle position) can also be measured.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eAP (front-to-back) ankle view with Méary cerclage\u003c\/strong\u003e — used to assess valgus. This measurement is considered \u003cstrong\u003epathological if greater than 8°\u003c\/strong\u003e. This view reveals tibiotalar joint morphology, occasional fibular fracture, medial laxity, and osteoarthritis with lateral joint-line narrowing and talar displacement (indicating grade IV disease).\u003c\/li\u003e\n\u003c\/ol\u003e\n\n\u003cp\u003e\u003cstrong\u003eStress X-rays\u003c\/strong\u003e are used to screen for joint laxity: forced valgus-varus views for the tibiotalar joint, abduction-adduction views for the Chopart joint, and elevation-lowering views for the Lisfranc joint.\u003c\/p\u003e\n\n\u003ch3\u003eUltrasound\u003c\/h3\u003e\n\u003cp\u003eUltrasound is an \u003cstrong\u003einexpensive but operator-dependent\u003c\/strong\u003e technique. It assesses the posterior tibial tendon and spring ligament, as well as all of the tibiotalar and medial midfoot ligaments.\u003c\/p\u003e\n\n\u003ch3\u003eMRI\u003c\/h3\u003e\n\u003cp\u003eMRI detects lesions in the posterior tibial tendon, spring ligament, and interosseous ligament, although the article notes that \u003cstrong\u003ecertain fissures or tears may be missed\u003c\/strong\u003e. In cases of impingement with the lateral tubercle of the talus, MRI can reveal cancellous bone edema (bruising) and cysts in the anterior apophysis of the calcaneus.\u003c\/p\u003e\n\n\u003ch3\u003eCT Scan\u003c\/h3\u003e\n\u003cp\u003eCT is used when the flatfoot is \u003cstrong\u003estiff (fixed)\u003c\/strong\u003e. In younger patients, it screens for talocalcaneal or calcaneonavicular \u003cstrong\u003esynostosis coalition\u003c\/strong\u003e (abnormal bone bridges). In older patients, it screens for osteoarthritis in the subtalar, tibiotalar, talonavicular, or Lisfranc joints. \u003cstrong\u003e3D CT reconstruction\u003c\/strong\u003e provides more precise analysis of bone and joint morphology, including the subtalar joint surface of the calcaneus (using a talar subtraction technique) — categorized per the \u003cstrong\u003eBunning classification\u003c\/strong\u003e — which is essential for planning an \u003cstrong\u003eEvans' osteotomy\u003c\/strong\u003e (a calcaneal lengthening procedure).\u003c\/p\u003e\n\n\u003ch2 id=\"classification\"\u003eTypes and Classifications of Flatfoot\u003c\/h2\u003e\n\n\u003cp\u003eAt the end of the clinical and imaging assessment, the flatfoot should be classified according to severity and cause.\u003c\/p\u003e\n\n\u003ch3\u003eSecondary Flatfoot\u003c\/h3\u003e\n\u003cp\u003eSome specific etiologies (causes) may be identified:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eOsseous (bone) origin:\u003c\/strong\u003e post-traumatic deformity or growth disorder\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eArticular (joint) origin:\u003c\/strong\u003e rheumatoid destruction, diabetic Charcot foot, or Marfan syndrome hyperlaxity\u003c\/li\u003e\n  \u003cli\u003e\u003cstrong\u003eTendon-muscle or neurologic origin\u003c\/strong\u003e\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003e\u003cstrong\u003eTraumatic causes are the most frequent\u003c\/strong\u003e, including neglected medial tibiotalar ligament or Lisfranc injuries, or malunion of talar or calcaneal fractures.\u003c\/p\u003e\n\n\u003ch3\u003eCongenital Flatfoot\u003c\/h3\u003e\n\u003cp\u003eReducible (flexible) idiopathic flatfoot in adults is \u003cstrong\u003erarely symptomatic\u003c\/strong\u003e. However, stiffness should always raise suspicion of a contracted flatfoot, synostosis coalition, or congenital or neurologic bone dysplasia. In congenital flatfoot, further morphologic changes continue to occur during growth.\u003c\/p\u003e\n\n\u003ch3\u003eDegenerative Flatfoot\u003c\/h3\u003e\n\u003cp\u003eDegenerative flatfoot \u003cstrong\u003etypically affects overweight menopausal women\u003c\/strong\u003e. It is important to distinguish between reducible and fixed forms. Researcher Bluman further divides these into \u003cstrong\u003evalgus and abduction forms\u003c\/strong\u003e for therapeutic planning. Doctors should systematically look for medial tibiotarsal (inner ankle) or first-ray hyperlaxity when evaluating degenerative flatfoot.\u003c\/p\u003e\n\n\u003ch3\u003eThe Raikin RAM Classification\u003c\/h3\u003e\n\u003cp\u003eFor surgical planning, the \u003cstrong\u003eRaikin classification (RAM)\u003c\/strong\u003e organizes flatfoot by three levels — hindfoot, ankle, and midfoot — with progressive severity (I, II, III). Below is a simplified summary:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eStage I (Hindfoot):\u003c\/strong\u003e Tenosynovitis (Ia) or tendinitis (Ib) of the posterior tibial tendon, with neutral alignment of the ankle and midfoot.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eStage IIa (Hindfoot):\u003c\/strong\u003e Flexible (supple) valgus flatfoot with talar coverage less than 40%, a talo-first metatarsal Méary angle under 30°, and a talocalcaneal incongruency angle of 20–45°. The ankle shows mild valgus (under 5°) or deltoid insufficiency, with mild flexible forefoot supination.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eStage IIb:\u003c\/strong\u003e More severe supple valgus flatfoot with talar coverage over 40%, Méary angle over 30°, and talocalcaneal incongruency angle over 45°. The ankle may show valgus with deltoid insufficiency and tibiotalar osteoarthritis; the midfoot shows supination with instability (but not yet arthritis).\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eStage IIIa (Hindfoot):\u003c\/strong\u003e Stiff, osteoarthritic valgus flatfoot (talar coverage under 40%, Méary under 30°, incongruency 20–45°). The ankle valgus is secondary to bone loss in the lateral tibial plafond with normal deltoid; the midfoot shows arthritic changes isolated to the medial column.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eStage IIIb:\u003c\/strong\u003e Stiff, osteoarthritic valgus flatfoot with talar coverage over 40% and Méary angle over 30°. The ankle valgus is due to both lateral tibial plafond bone loss \u003cem\u003eand\u003c\/em\u003e deltoid insufficiency; the midfoot shows medial and middle column arthritic changes.\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eIn the hindfoot, Raikin analyzes reducibility and abduction; in the ankle, valgus, medial laxity, and osteoarthritis; and in the midfoot, supination, first-ray hypermobility, and Lisfranc osteoarthritis.\u003c\/p\u003e\n\n\u003ch2 id=\"medical-treatment\"\u003eNon-Surgical Treatment\u003c\/h2\u003e\n\n\u003cp\u003eBefore considering surgery, medical treatments should be tried. The article notes they are of \u003cstrong\u003evarying efficacy\u003c\/strong\u003e:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eInsoles and shoes with rigid counters\u003c\/strong\u003e are most commonly advised. They may acceptably alleviate pain, but the deformity itself is \u003cstrong\u003enot corrected\u003c\/strong\u003e by this approach.\u003c\/li\u003e\n  \u003cli\u003eA \u003cstrong\u003esupination wedge or medial arch support\u003c\/strong\u003e can correct the valgus component but may worsen abduction. This can be compensated with an anterior pronation wedge if the deformity is reducible.\u003c\/li\u003e\n  \u003cli\u003eIn severe, non-operable forms, \u003cstrong\u003ecustomized orthopedic shoes\u003c\/strong\u003e are prescribed.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eRehabilitation (physiotherapy)\u003c\/strong\u003e should not be forgotten. It combats retraction of the triceps muscle (calf) or fibular tendons and reinforces the toe flexors to compensate for posterior tibial muscle weakness.\u003c\/li\u003e\n  \u003cli\u003eIn cases of \u003cstrong\u003eacute pain\u003c\/strong\u003e, the foot is immobilized for \u003cstrong\u003e2–6 weeks\u003c\/strong\u003e in a resin cast or strapping with the foot held in inversion (turned inward) — this can provide significant relief.\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003ch2 id=\"hindfoot-surgery\"\u003eSurgical Treatment: Hindfoot Procedures\u003c\/h2\u003e\n\n\u003cp\u003eWhen medical treatment fails, surgery is indicated. All hindfoot techniques described below can be used for \u003cstrong\u003ereducible (flexible) flatfoot\u003c\/strong\u003e, but only \u003cstrong\u003ehindfoot fusion\u003c\/strong\u003e is appropriate for fixed deformity.\u003c\/p\u003e\n\n\u003ch3\u003eMedial Translation Calcaneal Osteotomy\u003c\/h3\u003e\n\u003cp\u003eThis procedure, assessed and popularized by Myerson, corrects hindfoot valgus by shifting the calcaneal tuberosity (the back part of the heel bone) toward the inner side. This realigns the pull of the calcaneal (Achilles) tendon. The main drawback is that it increases lateral rotation of the foot, which must be compensated by tightening the posterior tibial tendon or repairing it with a tendon transfer if it is torn.\u003c\/p\u003e\n\n\u003ch3\u003eArthroereisis (Sinus Tarsi Implant)\u003c\/h3\u003e\n\u003cp\u003eArthroereisis was originally described for congenital childhood flatfoot, and its \u003cstrong\u003eapplication in adults is controversial\u003c\/strong\u003e. It works by limiting the abnormal motion in the subtalar joint. Two techniques are described:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003eThe \u003cstrong\u003e\"calcaneo-stop\" technique\u003c\/strong\u003e: a screw is placed vertically in the anterior apophysis of the calcaneus, positioned anterior to the reduced lateral process of the talus.\u003c\/li\u003e\n  \u003cli\u003eA \u003cstrong\u003emetal or polyethylene expansion screw\u003c\/strong\u003e placed in the sinus tarsi (a small canal on the outer side of the foot).\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eThis procedure acts on the subtalar joint but does not always fully correct the flatfoot, and it often needs to be combined with other tendon or bone procedures. The main drawback is \u003cstrong\u003efrequent sinus tarsi pain\u003c\/strong\u003e, which may require removal of the implant while trying to avoid secondary loss of correction.\u003c\/p\u003e\n\n\u003ch3\u003eEvans' Calcaneal Lengthening Osteotomy\u003c\/h3\u003e\n\u003cp\u003eThis procedure lengthens the anterior apophysis of the calcaneus using a triangular bone wedge. It corrects abduction and \u003cstrong\u003eautomatically raises the medial arch\u003c\/strong\u003e due to the oblique position of the talar head. The osteotomy pushes the navicular bone against the talar head, reducing talocalcaneal divergence and partially correcting hindfoot valgus through talar rotation. To achieve a proper windlass effect, it is essential to restore the talo-first metatarsal axis.\u003c\/p\u003e\n\n\u003cp\u003eDrawbacks and considerations include:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003eIncreased \u003cstrong\u003ecalcaneocuboid pressure\u003c\/strong\u003e, which can be compensated by lengthening the fibularis peroneus brevis tendon, provided talonavicular reduction is good.\u003c\/li\u003e\n  \u003cli\u003eAlternatively, \u003cstrong\u003ecalcaneocuboid fusion\u003c\/strong\u003e with a lengthening graft can be used, but carries a risk of non-union (failure of the bones to heal together).\u003c\/li\u003e\n  \u003cli\u003ePerforming the osteotomy through a blind lateral approach can involve the anteromedial or anterolateral subtalar joint surfaces, especially in \u003cstrong\u003eBunning type B2\u003c\/strong\u003e feet — though the article notes that the secondary osteoarthritis described in the literature was not consistently observed.\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eA variation, the \u003cstrong\u003eZ or Scarf calcaneal osteotomy\u003c\/strong\u003e described by Malerba and Weil, allows displacement in several planes at once: lengthening, varization (inward tilt), and translation.\u003c\/p\u003e\n\n\u003ch3\u003eHindfoot Fusion\u003c\/h3\u003e\n\u003cp\u003eThe most common procedure is \u003cstrong\u003esubtalar and mediotarsal fusion\u003c\/strong\u003e, which corrects subtalar valgus, medial arch collapse, and Chopart joint supination. Reduction should include talar rotation and anterior talar slide, reducing the height between the posterior edges of the calcaneus and tibia. This can, however, be very difficult or even incomplete.\u003c\/p\u003e\n\n\u003cp\u003eAdditional surgical details from the study:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eCalcaneocuboid fusion\u003c\/strong\u003e is not systematic but is necessary in osteoarthritic flatfoot with abduction, and should be combined with a lengthening graft.\u003c\/li\u003e\n  \u003cli\u003eA \u003cstrong\u003edual approach is classic\u003c\/strong\u003e, but a single medial approach is recommended to limit skin tension, reduce the risk of cicatricial necrosis (scar tissue breakdown), and allow tensioning of the posterior tibial tendon if it is not torn.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eIsolated talonavicular or subtalar fusion\u003c\/strong\u003e may be appropriate in cases of incipient (early) localized osteoarthritis.\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003ch2 id=\"ankle-surgery\"\u003eSurgical Treatment: Ankle Procedures\u003c\/h2\u003e\n\n\u003cp\u003eTibiotalar (ankle) valgus is a sign of severe, degenerative valgus flatfoot. It can be treated, but the article notes that results are \u003cstrong\u003emost reliable in post-traumatic valgus with medial collateral ligament injury\u003c\/strong\u003e, and less predictable in degenerative cases.\u003c\/p\u003e\n\n\u003ch3\u003eMedial Ligament Repair\u003c\/h3\u003e\n\u003cp\u003eFor traumatic lesions of the medial collateral (deltoid) ligament, the ligament is re-tensioned using a \u003cstrong\u003e\"pants over vest\" suture\u003c\/strong\u003e or a \u003cstrong\u003eshortening suture\u003c\/strong\u003e after resecting part of the distended ligament. The valgus should systematically be corrected with an associated calcaneal osteotomy.\u003c\/p\u003e\n\n\u003cp\u003eRepairing a \u003cstrong\u003edegenerative\u003c\/strong\u003e medial tibiotalar ligament with involvement of the spring ligament and posterior tibial tendon is difficult and currently under assessment. Because isolated re-tensioning and transosseous reinsertion tend to fail, the following \u003cstrong\u003etendon transfer\u003c\/strong\u003e options are recommended:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003ePlantaris tendon\u003c\/strong\u003e for Hintermann\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eFibularis peroneus longus tendon\u003c\/strong\u003e for Deland\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eHeterologous tendon graft\u003c\/strong\u003e (donor graft) for Myerson\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eThese transfers are placed in a non-anatomic trajectory because of the numerous bundles of the medial collateral ligament.\u003c\/p\u003e\n\n\u003ch3\u003eValgizing Tibiotalar Osteoarthritis\u003c\/h3\u003e\n\u003cp\u003eThe valgus may be reducible or fixed, and treatment differs accordingly:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003eIn \u003cstrong\u003emoderate osteoarthritis with misalignment\u003c\/strong\u003e, a \u003cstrong\u003esupramalleolar osteotomy\u003c\/strong\u003e (a corrective cut in the lower tibia) is feasible, sometimes combined with a malleolar repositioning osteotomy (lowering the lateral malleolus and shortening the medial malleolus).\u003c\/li\u003e\n  \u003cli\u003eIn \u003cstrong\u003esevere osteoarthritis where the foot can be realigned\u003c\/strong\u003e (usually by corrective fusion of the subtalar and Chopart joints), \u003cstrong\u003etotal ankle replacement\u003c\/strong\u003e may be indicated if the surgeon is experienced.\u003c\/li\u003e\n  \u003cli\u003eIn \u003cstrong\u003esevere osteoarthritis where the foot cannot be realigned\u003c\/strong\u003e, \u003cstrong\u003etibiotalocalcaneal fusion\u003c\/strong\u003e or combined ankle-and-hindfoot fusion will relieve pain — but with imperfect functional results.\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eThe article makes a strong point here: \u003cstrong\u003egiven the difficulty of managing tibiotalar involvement, symptomatic flatfoot should be treated before osteoarthritis sets in.\u003c\/strong\u003e\u003c\/p\u003e\n\n\u003ch2 id=\"midfoot-surgery\"\u003eSurgical Treatment: Midfoot Procedures\u003c\/h2\u003e\n\n\u003cp\u003eAfter treating the hindfoot, the midfoot should be systematically reassessed. The article warns that \u003cstrong\u003epersistent postoperative supination will induce valgization and jeopardize consolidation\u003c\/strong\u003e (bone healing).\u003c\/p\u003e\n\n\u003ch3\u003eSupination: First-Ray Lowering Osteotomy\u003c\/h3\u003e\n\u003cp\u003eThe first ray can be lowered at several levels:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003ePlantar subtraction of the first cuneiform\u003c\/strong\u003e (removing bone from the bottom) causes shortening.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eDorsal addition of the first cuneiform\u003c\/strong\u003e — recommended by Cotton — or addition at the first metatarsal base causes lengthening, with a stabilizing effect on hypermobility.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eThe drawback is a risk of creating a \u003cstrong\u003e\"tarsal hump\"\u003c\/strong\u003e (a bump on the top of the foot), which can make shoe-wearing difficult. When hallux valgus (bunion) is also present, lowering is achieved through a \u003cstrong\u003eScarf or chevron first metatarsal osteotomy\u003c\/strong\u003e.\u003c\/p\u003e\n\n\u003ch3\u003eFirst-Ray Hypermobility\u003c\/h3\u003e\n\u003cp\u003eDorsal addition of the first cuneiform can stabilize the first ray through a dorsal block effect. However, the \u003cstrong\u003etreatment of choice\u003c\/strong\u003e is the \u003cstrong\u003ecuneometatarsal fusion\u003c\/strong\u003e (the Lapidus procedure) and its variants. These are demanding techniques:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003eThe metatarsal bones must be positioned precisely to avoid \u003cstrong\u003emetatarsalgia by transfer\u003c\/strong\u003e (pain under the smaller toes) or excessive pressure under the first metatarsal head.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eNon-union is frequent\u003c\/strong\u003e, caused by insufficient fixation or by midfoot torsion from a short first metatarsal or abnormal metatarsal rotation.\u003c\/li\u003e\n  \u003cli\u003eA \u003cstrong\u003ebone graft\u003c\/strong\u003e may be necessary to maintain first metatarsal length, combined with anti-rotation fixation using an axial compression screw plus a dorsal plate.\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003ch3\u003eMidfoot Osteoarthritis\u003c\/h3\u003e\n\u003cp\u003eOsteoarthritis in the midfoot is either secondary to excessive midfoot torsion from supination, or from midfoot hypermobility that causes dorsal cuneometatarsal or cuneonavicular joint-line narrowing. Axial midfoot hyperpressure is also associated, due to first-ray insufficiency caused by hallux valgus or hypermobility. Treatment requires \u003cstrong\u003efusion of the first three cuneometatarsal joints\u003c\/strong\u003e and correction of the pronation-supination malalignment.\u003c\/p\u003e\n\n\u003ch3\u003eManaging Tendon Imbalance\u003c\/h3\u003e\n\u003cp\u003eManagement of calcaneal and fibular peroneus tendon retraction depends on severity and the technique used. In Evans' osteotomy and some arthroereisis cases, the fibularis peroneus brevis tendon (and more rarely the peroneus longus) is lengthened by \u003cstrong\u003etwo hemitenotomies on either side of the tendon\u003c\/strong\u003e — a technique that partially releases the tight tendon while preserving some function.\u003c\/p\u003e\n\n\u003ch2 id=\"implications\"\u003eWhat This Means for Patients\u003c\/h2\u003e\n\n\u003cp\u003eThe article's central message is clear: \u003cstrong\u003eadult flatfoot is often diagnosed and treated too late\u003c\/strong\u003e, and this delay has consequences — particularly for the ankle joint, where treatment is complex and poorly codified (lacking standardized protocols).\u003c\/p\u003e\n\n\u003cp\u003eFor patients, the key takeaways are:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003ePay attention to symptoms:\u003c\/strong\u003e Flatfoot only requires treatment when it causes pain or functional problems. Persistent inner-ankle pain, outer-foot pain, or difficulty walking should prompt evaluation.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eSeek a thorough assessment:\u003c\/strong\u003e A proper workup includes a detailed physical exam (not just looking at the arch) and weight-bearing X-rays. MRI, ultrasound, or CT may be needed to assess tendons, ligaments, and bone structure.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eTry non-surgical options first:\u003c\/strong\u003e Orthotics, supportive shoes, physiotherapy, and short-term cast immobilization (2–6 weeks) can manage many cases.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eConsider surgery early if indicated:\u003c\/strong\u003e Once arthritis develops in the ankle joint, surgical options become more limited and results less predictable. Treating symptomatic flatfoot \u003cem\u003ebefore\u003c\/em\u003e osteoarthritis sets in gives surgeons the best chance of preserving foot and ankle function.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eSurgical success depends on correcting all levels:\u003c\/strong\u003e Because flatfoot affects the hindfoot, ankle, and midfoot, a comprehensive surgical plan may combine multiple procedures — bone cuts (osteotomies), tendon transfers, and\/or fusions — tailored to the specific deformities found.\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003c!-- ddn:faq:start --\u003e\n\u003ch2 id=\"ddn-faq\"\u003eFrequently Asked Questions\u003c\/h2\u003e\n\u003ch3\u003eWhat is adult flatfoot and what causes it?\u003c\/h3\u003e\n\u003cp\u003eAdult flatfoot is a syndrome where the foot's inner arch collapses, often because it fails to lock during walking. It can involve the hindfoot, ankle, or midfoot, and is commonly caused by strain on the spring ligament, posterior tibial tendon, ankle ligaments, or midfoot structures. Trauma, such as old ankle sprains, can also contribute.\u003c\/p\u003e\n\u003ch3\u003eWhat symptoms should I pay attention to with flatfoot?\u003c\/h3\u003e\n\u003cp\u003eFlatfoot needs treatment only when it causes symptoms. Look for pain on the inner side of the foot along the posterior tibial tendon, swelling, or deeper pain in the sole. Outer foot pain may signal impingement. Also notice difficulty pushing off, bunions, or trouble walking. Persistent pain or functional problems should prompt evaluation.\u003c\/p\u003e\n\u003ch3\u003eHow is adult flatfoot diagnosed by a doctor?\u003c\/h3\u003e\n\u003cp\u003eA doctor will examine your foot while standing and lying down, testing arch collapse, heel position, toe raises, joint flexibility, and muscle strength. They look for signs like the 'too-many-toes sign' and assess whether deformities are flexible or fixed. They also check for joint stiffness or retracted tendons.\u003c\/p\u003e\n\u003ch3\u003eWhat non-surgical treatments are available for flatfoot?\u003c\/h3\u003e\n\u003cp\u003eNon-surgical options include insoles, shoes with rigid counters, and medial arch supports, which may ease pain but do not correct the deformity. Physiotherapy combats muscle retraction and reinforces toe flexors. For acute pain, foot immobilization in a cast or strapping for 2–6 weeks can provide significant relief.\u003c\/p\u003e\n\u003ch3\u003eWhen is surgery for flatfoot recommended and what does it involve?\u003c\/h3\u003e\n\u003cp\u003eSurgery is considered when non-surgical treatment fails. For flexible flatfoot, procedures like calcaneal osteotomy, arthroereisis, or Evans osteotomy can realign bones. For fixed deformity, hindfoot fusion is used. Ankle or midfoot procedures may also be needed. Surgery targets all affected levels, often combining bone cuts, tendon transfers, or fusions.\u003c\/p\u003e\n\u003c!-- ddn:faq:end --\u003e\n\n\u003ch2 id=\"source\"\u003eSource Information\u003c\/h2\u003e\n\n\u003cp\u003eThis patient-friendly article is based on the following peer-reviewed research:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eOriginal title:\u003c\/strong\u003e \"Adult flatfoot\"\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eAuthor:\u003c\/strong\u003e E. Toullec\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eJournal:\u003c\/strong\u003e Orthopaedics \u0026amp; Traumatology: Surgery \u0026amp; Research\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003ePublication date:\u003c\/strong\u003e February 2015 (Volume 101, Issue 1, Pages S11–S17)\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eCopyright:\u003c\/strong\u003e © 2014 Elsevier Masson SAS\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eNote: This article has been substantially rewritten in plain language for educational purposes. It does not replace professional medical advice. Patients experiencing foot pain or flatfoot symptoms should consult a qualified healthcare provider, preferably a foot and ankle specialist or orthopedic surgeon.\u003c\/p\u003e","brand":"DiagnosticDetectives.Com","offers":[{"title":"Default Title","offer_id":47459220422812,"sku":null,"price":0.0,"currency_code":"EUR","in_stock":true}],"url":"https:\/\/diagnosticdetectives.ae\/products\/understanding-adult-flatfoot-a-complete-guide-to-diagnosis-and-treatment","provider":"DiagnosticDetectives.Com","version":"1.0","type":"link"}