Journal of Foot and Ankle Surgery (Asia Pacific)

Register      Login

VOLUME 8 , ISSUE 2 ( April-June, 2021 ) > List of Articles


A Clinical Approach to Diagnose Flatfoot Deformity

Chamnanni Rungprai, Parinya Maneeprasopchoke

Citation Information : Rungprai C, Maneeprasopchoke P. A Clinical Approach to Diagnose Flatfoot Deformity. J Foot Ankle Surg Asia-Pacific 2021; 8 (2):48-54.

DOI: 10.5005/jp-journals-10040-1149

License: CC BY-NC 4.0

Published Online: 01-06-2021

Copyright Statement:  Copyright © 2021; The Author(s).


Flatfoot is a complex disorder combining multiple static and dynamic deformities, associated with a collapsing medial longitudinal arch. The etiology of flatfoot is multifactorial and can be divided into two main groups; congenital and acquired groups. History, physical examination, and radiographs of the foot are used to establish and confirm the diagnosis. The staging system for flatfoot demonstrates the deformity and guides the appropriate treatment. This article will focus on etiologies, pathophysiology, and clinical approach to diagnose flatfoot deformity.

  1. Current concept review: acquired adult flatfoot deformity. Foot Ankle Int 2006;27(1):66–75. DOI: 10.1177/107110070602700113.
  2. Posterior tibial tendon rupture: a refined classification system. Foot Ankle Clin 2007;12(2):233–249. DOI: 10.1016/j.fcl.2007.03.003v.
  3. Pediatric pes planus: a state-of-the-art review. Pediatrics 2016;137(3):e20151230. DOI: 10.1542/peds.2015-1230.
  4. Pediatric flatfoot: pearls and pitfalls. Foot Ankle Clin 2017;22(3):643–656. DOI: 10.1016/j.fcl.2017.04.008.
  5. Isolated spring ligament failure as a cause of adult-acquired flatfoot deformity. Foot Ankle Int 2013;34(6):818–823. DOI: 10.1177/1071100713483099.
  6. Adult acquired flatfoot deformity: treatment of dysfunction of the posterior tibial tendon. Instruct Course Lect 1997;46:393–405.
  7. Tibialis posterior tendon dysfunction. Clin Orthopaed Relat Res 1989(239):196–206. DOI: 10.1097/00003086-198902000-00022.
  8. The prevalence of symptomatic posterior tibialis tendon dysfunction in women over the age of 40 in England. Foot Ankle Surg 2009;15(2):75–81. DOI: 10.1016/j.fas.2008.08.003.
  9. Acquired adult flat foot secondary to posterior tibial-tendon pathology. J Bone Joint Surg Am Vol 1986;68(1):95–102. DOI: 10.2106/00004623-198668010-00012.
  10. Tibialis posterior tendon rupture. Clin Orthopaed Relat Res 1983(177):140–147. DOI: 10.1097/00003086-198307000-00021.
  11. Posterior tibial tendon dysfunction: Its association with seronegative inflammatory disease. Foot Ankle 1989;9(5):219–225. DOI: 10.1177/107110078900900503.
  12. Posterior tibial tenosynovitis secondary to foot strain. Clin Orthop Relat Res 1965;42(42):101–102. DOI: 10.1097/00003086-196500420-00013.
  13. Possible epidemiological factors associated with rupture of the posterior tibial tendon. Foot Ankle 1992;13(2):70–79. DOI: 10.1177/107110079201300204.
  14. Vascularity of the posterior tibial tendon. J Bone Joint Surg Am Vol 1990;72(6):884–888. DOI: 10.2106/00004623-199072060-00014.
  15. Spontaneous rupture of the tibialis posterior tendon: Clinical findings, tenographic studies, and a new technique of repair. Foot Ankle 1982;3(3):158–166. DOI: 10.1177/107110078200300308.
  16. The blood supply of the posterior tibial tendon. J Bone Joint Surg Br 2002;84(1):141–144. DOI: 10.1302/0301-620X.84B1.0840141.
  17. MMP-1 promoter genotype and haplotype association with posterior tibial tendinopathy. Gene 2014;547(2):334–337. DOI: 10.1016/j.gene.2014.07.001.
  18. MMP-8 polymorphism is genetic marker to tendinopathy primary posterior tibial tendon. Scandinav J Med Sci Spor 2014;24(1):220–223. DOI: 10.1111/j.1600-0838.2012.01469.x.
  19. Posterior tibial tendinopathy associated with matrix metalloproteinase 13 promoter genotype and haplotype. J Gene Med 2016;18(11-12):325–330. DOI: 10.1002/jgm.2934.
  20. The longitudinal arch. A survey of eight hundred and eighty-two feet in normal children and adults. J Bone Joint Surg Am Vol 1987;69(3):426–428. DOI: 10.2106/00004623-198769030-00014.
  21. The typically developing paediatric foot: how flat should it be? a systematic review. J Foot Ankle Res 2017;10(1):37. DOI: 10.1186/s13047-017-0218-1.
  22. Paediatric flexible flat foot: how are we measuring it and are we getting it right? A systematic review. J Foot Ankle Res 2018;11(1):21. DOI: 10.1186/s13047-018-0264-3.
  23. Prevalence of flat foot in preschool-aged children. Pediatrics 2006;118(2):634–639. DOI: 10.1542/peds.2005-2126.
  24. Risk factors that may adversely modify the natural history of the pediatric pronated foot. Clin Podiat Med Surg 2000;17(3):397–417.
  25. Assessment of the medial longitudinal arch in children and adolescents with obesity: footprints and radiographic study. Eur J Pediatr 2009;168(5):559–567. DOI: 10.1007/s00431-008-0789-8.
  26. Pediatric flexible flatfoot; clinical aspects and algorithmic approach. Iranian J Pediatr 2013;23(3):247–260.
  27. Diagnosis and treatment of pediatric flatfoot. J Foot Ankle Surg 2004;43(6):341–373. DOI: 10.1053/j.jfas.2004.09.013.
  28. Rigid pediatric pes planovalgus: conservative and surgical treatment options. Clin Podiat Med Surg 2010;27(1):79–92. DOI: 10.1016/j.cpm.2009.08.004.
  29. Adult-acquired flatfoot deformity. J Am Acad Orthopaed Surg 2008;16(7):399–406. DOI: 10.5435/00124635-200807000-00005.
  30. Pathology of the posterior tibial tendon in posterior tibial tendon insufficiency. Foot Ankle Int 1998;19(8):520–524. DOI: 10.1177/107110079801900803.
  31. Gliding resistance of the posterior tibial tendon. Foot Ankle Int 2006;27(9):723–727. DOI: 10.1177/107110070602700912.
  32. Acute posttraumatic planovalgus foot deformity involving hindfoot ligamentous pathology. Foot Ankle Clin 2003;8(3):521–537. DOI: 10.1016/S1083-7515(03)00049-4.
  33. Adult-acquired flatfoot deformity: etiology, diagnosis, and management. JBJS Rev 2017;5(8):e7. DOI: 10.2106/JBJS.RVW.16.00116.
  34. Adult-acquired flatfoot deformity. Foot Ankle Orthopaed 2019;4(1):247301141882084. DOI: 10.1177/2473011418820847.
  35. The adult acquired flatfoot and spring ligament complex: Pathology and implications for treatment. Foot Ankle Clin 2001;6(1):129–135. DOI: 10.1016/S1083-7515(03)00086-X.
  36. Acquired adult flat foot due to isolated plantar calcaneonavicular (spring) ligament insufficiency with a normal tibialis posterior tendon. Foot Ankle Surg 2008;14(2):89–95. DOI: 10.1016/j.fas.2007.11.005.
  37. Tibialis posterior tendon rupture: a cause of rheumatoid flat foot. Arthritis Rheumatism 1988;31(3):441–446. DOI: 10.1002/art.1780310319.
  38. Treatment of the diabetic neuropathic flatfoot. Techniq Orthopaed 2000;15(3):277–289. DOI: 10.1097/00013611-200015030-00014.
  39. On arthropathies of cerebral or spinal origin. Clin Orthop Relat Res 1993;296:4–7.
  40. The flexible flatfoot in the adult. Foot Ankle Clin 2007;12(2):251–271. DOI: 10.1016/j.fcl.2007.03.008vi.
  41. Subluxation of the talocalcaneal joint in adults who have symptomatic flatfoot. J Bone Joint Surg Am Vol 1999;81(8):1147–1154. DOI: 10.2106/00004623-199908000-00010.
  42. Talocalcaneal and subfibular impingement in symptomatic flatfoot in adults. J Bone Joint Surg Am 2002;84(11):2005–2009. DOI: 10.2106/00004623-200211000-00015.
  43. Long-term follow-up of patients undergoing tibialis posterior transfer: is acquired pes planus a complication? Foot 2018;34:83–89. DOI: 10.1016/j.foot.2017.11.008.
  44. Variations on the insertion of the posterior tibialis tendon: a cadaveric study. Foot Ankle Int 2003;24(10):780–783. DOI: 10.1177/107110070302401008.
  45. Function of the posterior tibial tendon muscle. Foot Ankle Clin 2001;6(1):1–14. DOI: 10.1016/S1083-7515(03)00071-8.
  46. Preliminary gait analysis results after posterior tibial tendon reconstruction: a prospective study. Foot Ankle Int 2004;25(2):96–100. DOI: 10.1177/107110070402500210.
  47. The effect of posterior tibialis tendon dysfunction on the plantar pressure characteristics and the kinematics of the arch and the hindfoot. Clin Biomechan 2004;19(2):161–169. DOI: 10.1016/j.clinbiomech.2003.10.007.
  48. Effect of the posterior tibial tendon on the arch of the foot during simulated weightbearing: biomechanical analysis. Foot Ankle Int 1997;18(1):43–46. DOI: 10.1177/107110079701800109.
  49. Deltoid ligament forces after tibialis posterior tendon rupture: effects of triple arthrodesis and calcaneal displacement osteotomies. Foot Ankle Int 1995;16(1):14–20. DOI: 10.1177/107110079501600104.
  50. New radiographic parameters assessing forefoot abduction in the adult acquired flatfoot deformity. Foot Ankle Int 2009;30(12):1168–1176. DOI: 10.3113/FAI.2009.1168.
  51. Reduction of the uncrossed two-joints muscles of the leg to one-joint muscles in spastic conditions. Acta Chir Scandinav 1924;56:315–330.
  52. Radiographic assessment of adult flatfoot. Foot Ankle Int 2005;26(10):820–825. DOI: 10.1177/107110070502601006.
  53. New radiographic parameter assessing hindfoot alignment in stage II adult-acquired flatfoot deformity. Foot Ankle Int 2015;36(4):417–423. DOI: 10.1177/1071100714558846.
  54. Effect of calcaneal lengthening on relationships among the hindfoot, midfoot, and forefoot. Foot Ankle 1993;14(3):136–141. DOI: 10.1177/107110079301400305.
  55. Posterior tibial tendon insufficiency results at different stages. HSS J 2006;2(2):157–160. DOI: 10.1007/s11420-006-9017-0.
  56. Contribution of lateral column lengthening to correction of forefoot abduction in stage IIb adult acquired flatfoot deformity reconstruction. Foot Ankle Int 2015;36(12):1400–1411. DOI: 10.1177/1071100715596607.
  57. Stage IV posterior tibial tendon rupture. Foot Ankle Clin 2007;12(2):341–362. DOI: 10.1016/j.fcl.2007.03.004viii.
  58. The hindfoot alignment view. Foot Ankle Int 1995;16(9):572–576. DOI: 10.1177/107110079501600911.
  59. Rupture of the posterior tibial tendon: CT and surgical findings. Radiology 1988;167(2):489–493. DOI: 10.1148/radiology.167.2.3357960.
  60. Assessment of lateral hindfoot pain in acquired flatfoot deformity using weightbearing multiplanar imaging. Foot Ankle Int 2010;31(5):361–371. DOI: 10.3113/FAI.2010.0361.
  61. Flexible adult acquired flatfoot deformity: Comparison between weight-bearing and non-weight-bearing measurements using cone-beam computed tomography. J Bone Joint Surg Am 2017;99(18):e98. DOI: 10.2106/JBJS.16.01366.
  62. Functional outcomes of tibialis posterior tendoscopy with comparison to magnetic resonance imaging. Foot Ankle Int 2015;36(7):812–819. DOI: 10.1177/1071100715576485.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.