Symptoms
As a rule, patients with a fallen arches have no symptoms. In a few cases, a massively pronounced kinked foot can lead to an incarceration at the calcaneus and then cause massive pain in the area of the outer ankle. If a clubfoot occurs at an advanced age, arthrosis can develop which leads to movement disorders.
The infantile splayfoot is usually also without symptoms. If pain occurs, other foot malpositions should always be excluded. The flexible flat-foot is the much more common variant.
The transitions between abnormal and normal are fluid. In infants, deviations of angles of up to 20° are still within the normal range, in school children up to 10°. The foot is not stiffened and can be moved back and forth with the hands and brought into the normal position.
If the patient is asked to stand on his toes, the deformity can be compensated, the heel now points inwards rather than outwards and the inner edge of the foot bulges. Causes can be weak muscles or ligaments, overweight, paralysis or knock-knees. The therapy accordingly involves strengthening the muscles through specific exercises, e.g. physiotherapy, but frequent barefoot walking on uneven ground is often sufficient.
In small children, the foot often returns to its normal position on its own by the time they start school, so that the prognosis for the flexible flat-foot with buckling is good. Exceptions are flat feet due to bony malformations. If the flat foot does not recede due to training or if it has a particularly pronounced form, orthopedic insoles can also be used for therapy.
These insoles must primarily form a wedge-shaped support on the inner edge of the foot, so that the kinking of the foot can be compensated. There are insoles for the entire foot as well as heel shells that leave the forefoot free. Instead of insoles, orthopedic shoes can also be prescribed that have an elevation of the inner shoe edge built in.
In very rare cases, where the flexible buckling and flat foot is very pronounced and causes pain, the malposition can also be treated surgically. In this case, the tendon of the front shin muscle is displaced in such a way that the inner edge of the foot is actively raised and the arch of the foot is restored.This is a much rarer malposition of the foot, where the foot cannot be brought back into its natural position with the hands. The joint therefore appears stiff, and is referred to as a rigid or contractile flat foot.
The causes of this can either be congenital, e.g. in the form of a malformation of the calf bone, which leads to a changed structure of the ankle joint, or acquired. Acquired causes include changes due to rheumatoid arthritis or accidents and other injuries. Inequalities in the interplay of the muscles, e.g. in spastic paralysis, can also be responsible.
Diagnostically, the foot is first examined while lying, standing and walking. Patients with a rigid flat-foot with buckling can no longer compensate for the defective position, and it is virtually impossible to stand on tiptoe. In addition, both the upper and lower ankle joint show significant stiffening and the associated movement restrictions.
As a rule, an X-ray of the foot is then taken in two planes while standing in order to best assess the bony structures. Therapeutically, physiotherapy and orthopedic insoles and shoes (see above) are also prescribed, whereby the focus here is clearly on correction by orthopedic technology. However, it is equally important to treat the underlying disease, e.g. the adequate treatment of rheumatoid arthritis.
Surgical procedures are also used for paralysis, as is the case with infantile cerebral palsy, epileptic encephalopathy or meningomyelocele. There are two procedures in the foreground. In the Grice-Green method, the lower ankle joint is artificially stiffened so that the pigeon-toed foot is lifted.
Another method is the Evants method, in which a bone wedge – usually from the fibula – is inserted into the heel bone to create stability and straighten the foot. With the latter, the mobility in the ankle joint is maintained. Step one of the therapy, however, always consists of consultation, physiotherapy and correction using orthopedic technology. If the X-rays taken for follow-up examinations show no improvement, stage two can be discussed in the form of surgical therapy. In any case, a gait analysis should be performed first to ensure that surgery can restore the gait pattern.
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