Flatfoot (Pes Planus)

Flatfoot, also known as pes planus, describes a foot shape in which the arch is lower than expected and more of the sole comes into contact with the ground while standing.

Flatfoot can occur in children and adults, and it may be flexible or rigid. Many people with flat feet have no pain and do not require treatment, while others develop arch pain, heel pain, ankle discomfort, fatigue, difficulty with prolonged standing, or problems during walking and sports.

What Is Flatfoot?

Flatfoot is a general term used when the medial longitudinal arch of the foot is reduced.

The condition can vary considerably. In some patients, the arch becomes lower only when standing and returns when the foot is unloaded. In others, the foot remains flat and stiff regardless of position.

For this reason, simply looking at the arch is not enough. Foot flexibility, heel alignment, joint movement, muscle and tendon function, age, and symptoms should all be considered.

What Does Pes Planus Look Like?

Typical findings may include:

• A low or absent arch while standing
• More of the sole contacting the floor
• The heel tilting outward
• The forefoot appearing to turn outward
• Shoes wearing unevenly
• One or both feet appearing flattened
• Changes in walking pattern in symptomatic patients

The appearance of the foot does not always reflect the severity of symptoms. Some people with very low arches remain completely comfortable.

What Are the Symptoms of Flatfoot?

Flatfoot may cause no symptoms at all. When symptoms are present, they may include:

• Arch pain
• Heel pain
• Pain along the inner side of the ankle
• Foot fatigue during prolonged standing
• Difficulty walking long distances
• Swelling around the inner ankle
• Ankle or lower-leg discomfort
• Reduced tolerance for running or sports
• Difficulty finding comfortable footwear

Flexible Flatfoot and Rigid Flatfoot

One of the most important distinctions is whether the foot is flexible or rigid.

Rigid flatfoot generally requires closer evaluation because it may be associated with structural abnormalities, arthritis, or other underlying conditions.

Is Flatfoot Normal in Children?

Flat feet are very common in young children. The arch develops gradually as the foot grows, and soft tissue beneath the arch can make the foot appear flatter during early childhood.

A painless, flexible flatfoot in a child often represents a normal variation and may not require treatment.

Evaluation becomes more important when the child has pain, stiffness, asymmetry, difficulty walking, or a foot that is becoming progressively more deformed.

What Causes Flatfoot?

Flatfoot can have many different causes, depending on age and whether the deformity is flexible or rigid.

Possible contributing factors may include:

• Inherited foot structure
• Ligament flexibility
• Achilles tendon or calf tightness
• Muscle or tendon imbalance
• Posterior tibial tendon dysfunction
• Progressive collapsing foot deformity
• Arthritis
• Previous injury
• Neurological conditions
• Congenital structural abnormalities

Flatfoot in Adults

Some adults have had flexible flat feet since childhood and never develop significant symptoms.

In other adults, the arch may gradually collapse because of changes in tendons, ligaments, joints, or foot alignment.

New or progressive flatfoot in adulthood should therefore be evaluated differently from a painless flexible flatfoot that has been present for many years.

Adult Acquired Flatfoot and Progressive Collapsing Foot Deformity

A progressive flattening of the adult foot is now often described as progressive collapsing foot deformity.

This condition may involve the posterior tibial tendon, supporting ligaments, joints, and overall alignment of the foot.

Patients may notice pain along the inner ankle, progressive loss of the arch, outward movement of the forefoot, difficulty standing on one leg and rising onto the toes, or increasing stiffness.

Treatment depends on flexibility, severity, tendon function, ligament stability, and whether arthritis is present.

Posterior Tibial Tendon and Flatfoot

The posterior tibial tendon helps support the arch and contributes to foot stability during walking.

Dysfunction or degeneration of this tendon may contribute to progressive flatfoot in some adults.

However, adult flatfoot is often more complex than a tendon problem alone, which is why ligaments, joints, and alignment should also be evaluated.

Can Achilles Tendon Tightness Contribute to Flatfoot?

Tightness of the Achilles tendon or calf muscles can limit upward ankle movement.

When the ankle cannot move normally, the foot may compensate by flattening or rotating during walking.

Achilles flexibility is therefore commonly evaluated in patients with symptomatic flatfoot.

Rigid Flatfoot

Rigid flatfoot differs from the more common flexible form because the arch does not return when the patient sits or stands on tiptoe.

The foot may also be painful or stiff, and joint motion may be limited.

Possible causes include tarsal coalition, arthritis, congenital deformity, previous trauma, and other structural conditions.

Persistent rigid flatfoot should be evaluated to identify the underlying cause rather than being treated simply as a low arch.

What Is Tarsal Coalition?

Tarsal coalition is an abnormal connection between two or more bones of the foot and can be one cause of painful rigid flatfoot, particularly in children and adolescents.

Symptoms may include foot stiffness, recurrent ankle sprains, pain during activity, and reduced side-to-side movement of the hindfoot.

Imaging may be required when a coalition is suspected.

Can Flatfoot Cause Ankle Pain?

Yes. Changes in heel alignment and arch support can alter the forces around the ankle.

Patients may experience discomfort along the inner ankle, particularly when posterior tibial tendon structures are involved.

In more advanced deformities, pain may also develop on the outer side of the ankle because of altered alignment and impingement.

Can Flatfoot Cause Knee or Leg Pain?

Foot alignment can influence the way forces travel through the lower limb, but flatfoot should not automatically be assumed to be the cause of every knee, hip, or leg complaint.

When pain occurs in several areas, the entire lower limb should be examined to determine which structures are actually responsible for the symptoms.

How Is Flatfoot Diagnosed?

Diagnosis begins with a detailed orthopedic examination while the patient is standing, walking, and sitting.

The examination may assess:

• Arch height
• Heel alignment
• Foot flexibility
• Ankle movement
• Achilles tendon tightness
• Posterior tibial tendon function
• Muscle strength
• Toe position
• Walking pattern
• Areas of tenderness

What Is the Heel-Rise Test?

The heel-rise test can provide useful information about foot flexibility and posterior tibial tendon function.

A patient may be asked to rise onto the toes while standing on one or both feet.

In a flexible foot, the arch may become more visible and the heel may move toward a corrected position.

Difficulty performing a single-leg heel rise may be relevant in adults with suspected posterior tibial tendon dysfunction or progressive collapsing foot deformity.

Are X-Rays Necessary for Flatfoot?

X-rays are not required for every painless flexible flatfoot.

When significant pain, stiffness, progressive deformity, asymmetry, suspected arthritis, or surgical planning is involved, weight-bearing X-rays can provide important information.

Standing images show how the bones align while the foot is supporting body weight.

When Are MRI or CT Scans Used?

MRI may be considered when tendon, ligament, cartilage, or other soft-tissue problems need further evaluation.

CT imaging may be useful in selected rigid deformities, suspected tarsal coalition, arthritis, or complex bony abnormalities.

Imaging should be selected according to the clinical findings rather than routinely performed in every patient.

Does Flatfoot Need Treatment?

Not every flatfoot requires treatment.

A painless flexible flatfoot that does not affect walking, sports, or daily activities may simply be observed.

Treatment is usually directed toward symptoms such as pain, fatigue, progressive deformity, instability, or functional limitation rather than the appearance of the arch alone.

Non-Surgical Treatment for Flatfoot

Do Orthotics Correct Flat Feet Permanently?

Orthotics can improve comfort, support, and pressure distribution in selected patients, but they generally do not permanently change the underlying bone structure of an established flatfoot.

Their purpose is mainly functional and symptom-related.

Orthotics should therefore be selected according to the type of flatfoot and the patient's symptoms rather than used automatically in everyone with a low arch.

Can Exercises Fix Flat Feet?

Exercises may improve strength, balance, ankle mobility, and muscular control.

They may be useful in symptomatic flexible flatfoot or as part of rehabilitation, but they do not usually permanently reverse a rigid structural deformity.

Do Children With Flat Feet Need Special Shoes?

Most children with painless flexible flatfoot do not automatically need corrective shoes.

Comfortable footwear is usually sufficient when there is no pain or functional problem.

Orthotics or other supports may be considered for selected symptomatic children after orthopedic evaluation.

Can Flatfoot Get Worse Over Time?

Some flat feet remain stable throughout life, while others may become progressively more symptomatic or structurally deformed.

Progression is particularly important in adults who notice a newly collapsing arch, increasing heel valgus, inner ankle pain, weakness, or difficulty performing a heel rise.

A changing foot shape should be reassessed rather than assumed to be the same as a long-standing painless flatfoot.

When Is Flatfoot Surgery Considered?

Surgery is not required for most painless flexible flat feet.

Surgical treatment may be considered when persistent pain, progressive deformity, significant functional limitation, tendon dysfunction, joint instability, or arthritis continues despite appropriate non-surgical treatment.

The procedure depends on the cause, flexibility, age, alignment, and condition of the joints.

Flatfoot Surgery

There is no single operation that is appropriate for every patient with pes planus.

Surgical reconstruction may involve a combination of soft-tissue procedures, tendon procedures, osteotomies, ligament reconstruction, Achilles or calf procedures, or joint fusion in advanced rigid and arthritic deformities.

The goal is to create a more balanced, stable, plantigrade foot and improve function rather than simply creating a visually higher arch.

Osteotomy for Flatfoot

Osteotomy means surgically cutting and repositioning a bone to improve alignment.

Heel and midfoot osteotomies may be used in selected flexible deformities to reposition the foot while preserving joint movement.

The exact procedure depends on where the deformity originates and how the foot behaves during weight bearing.

Tendon Procedures for Flatfoot

Tendon procedures may be used when muscle imbalance or posterior tibial tendon dysfunction contributes to the deformity.

A tendon procedure alone may not be sufficient when significant bone alignment or ligament problems are also present.

Reconstruction is therefore planned according to the whole deformity rather than one structure in isolation.

When Is Fusion Surgery Used?

Fusion may be considered in advanced rigid flatfoot with significant arthritis or deformity that cannot be adequately corrected with joint-preserving procedures.

Fusion stabilizes selected joints in a more functional position but reduces movement at those joints.

The potential benefits and limitations should be discussed individually before surgery.

Recovery After Flatfoot Surgery

Recovery varies considerably according to the procedures performed.

Complex flatfoot reconstruction often involves bone and soft-tissue healing, so a period of protection and restricted weight bearing may be required.

Rehabilitation is gradually introduced to restore movement, strength, balance, and walking function.

Return to sports generally takes longer than return to routine daily activities.

When Can I Walk After Flatfoot Surgery?

Weight-bearing recommendations depend on whether osteotomies, tendon procedures, ligament reconstruction, or fusion have been performed.

A cast or protective boot may be used during the initial healing period.

Walking is increased gradually according to healing and follow-up findings rather than according to a single timetable for every patient.

When Should You See an Orthopedic Specialist?

An orthopedic evaluation may be appropriate if:

• Your flat feet are persistently painful
• The arch is progressively collapsing
• One foot has changed significantly more than the other
• You have pain or swelling along the inner ankle
• The foot has become stiff
• You cannot comfortably rise onto the toes
• Walking or sports are becoming difficult
• A child has painful or rigid flatfoot
• Symptoms continue despite appropriate non-surgical treatment

Flatfoot Treatment in Antalya

Flatfoot is not a single diagnosis that requires the same treatment in every patient. Flexible childhood flatfoot, adult progressive collapsing foot deformity, rigid flatfoot, tendon-related problems, and arthritic deformities should be evaluated differently.

During an orthopedic examination, arch height, heel position, flexibility, Achilles tendon length, posterior tibial tendon function, joint movement, muscle strength, walking pattern, and weight-bearing alignment can be assessed together.

Depending on the findings, treatment may include observation, footwear modification, orthotic support, stretching, rehabilitation, bracing, or individualized surgical reconstruction in appropriately selected patients.

Frequently Asked Questions About Flatfoot

What is pes planus?

Pes planus is the medical term for flatfoot, a condition in which the arch of the foot is lower than expected while standing.

Are flat feet always abnormal?

No. Many people have flexible flat feet without pain or functional limitation and do not need treatment.

What is the difference between flexible and rigid flatfoot?

In flexible flatfoot, the arch returns when the foot is unloaded or when standing on the toes. In rigid flatfoot, the arch remains low and joint movement may be restricted.

Do children grow out of flat feet?

The arch often becomes more visible as children grow. Many young children have painless flexible flatfoot as part of normal development.

Can flat feet cause pain?

Yes. Some patients develop arch pain, heel pain, ankle discomfort, fatigue, or reduced tolerance for prolonged walking and sports.

Do insoles cure flat feet?

Insoles may improve support and reduce symptoms, but they generally do not permanently change the structural shape of the foot.

Can exercises correct flat feet?

Exercises can improve strength, flexibility, balance, and control, but they do not usually reverse a rigid structural deformity.

Can adults suddenly develop flat feet?

Yes. Progressive arch collapse in adulthood can occur because of tendon, ligament, joint, or alignment problems and should be evaluated when it is new or worsening.

Does flatfoot always need surgery?

No. Surgery is generally reserved for selected patients with persistent pain, progressive deformity, functional limitation, or structural problems that do not respond adequately to non-surgical treatment.

When should flat feet be examined?

Evaluation is appropriate when flatfoot is painful, rigid, asymmetric, progressively worsening, or interfering with walking, work, or sports.