Adolescent flatfoot and progressive collapsing foot deformity
Some adolescents have a flat foot that hurts, gets tired or worsens over time. When conservative treatment is not enough, there are surgical techniques to rebuild the arch, such as calcaneal lengthening osteotomy with porous titanium wedges and cuneiform osteotomy to correct supination and plantarflex the foot.
- Typical age
- Adolescence
- Also known as
- Progressive collapsing foot deformity · Symptomatic planovalgus foot · Rigid flatfoot
What is it?
Rigid flatfoot is a condition in which the arch is reduced or absent and, unlike flexible flatfoot, it does not reappear when the child stands on tiptoe or takes weight off the foot. There is also usually limited movement in the foot joints, especially the subtalar joint, which is responsible for much of the foot’s ability to adapt to the ground.
Unlike flexible flatfoot, which is common in childhood and usually part of normal development, rigid flatfoot needs a specialist assessment to identify its cause and decide whether treatment is needed.
Signs parents may notice
Symptoms depend on the cause, the child’s age and the degree of stiffness. Some patients have a deformity without pain, while others develop discomfort that limits physical activity.
The most common signs and symptoms are:
- Pain on the outer edge of the foot, in the hindfoot or around the ankle.
- Stiffness and reduced foot movement.
- Difficulty standing on tiptoe or adapting the foot to uneven ground.
- Repeated ankle sprains.
- Tiredness or discomfort when walking, running or playing sport.
- A flat foot that persists when standing on tiptoe.
- Spasm of the peroneal muscles, which can hold the foot in a protective position and limit its movement even further.
When to see a specialist
Persistent pain, stiffness or recurrent sprains in a child or adolescent with flat feet should prompt an assessment by a paediatric orthopaedic specialist.
How is it diagnosed?
Diagnosis is based on a careful clinical examination and imaging tests chosen according to the suspected cause.
Clinical examination
The specialist assesses the shape of the foot when standing, hindfoot movement, the ability to raise the heels on tiptoe, pain and ankle movement. Walking is also analysed and signs of muscle spasm or other associated problems are looked for.
X-rays
Weight-bearing X-rays of the foot show bone alignment, the height of the arch and possible structural changes. In some coalitions they can show indirect signs of the abnormal connection between bones.
Computed tomography (CT)
CT precisely defines the bone anatomy of a tarsal coalition, its extent and its relationship with neighbouring joints. It can be particularly useful for planning surgery.
Magnetic resonance imaging (MRI)
MRI can identify fibrous or cartilaginous coalitions that may not be clearly visible on X-rays. It also provides information about cartilage, soft tissues and possible associated injuries.
The choice of tests depends on the clinical findings and the suspected diagnosis. Not every patient needs every test.
Causes of rigid flatfoot
Several conditions can cause rigid flatfoot in childhood and adolescence. Correctly identifying the cause is essential to choose the most appropriate treatment.
1. Tarsal coalitions (see tarsal coalition)
Tarsal coalitions are one of the most important causes of rigid flatfoot in children and adolescents. They are congenital anomalies that arise during embryonic development, when two or more tarsal bones do not separate completely and remain joined by fibrous, cartilaginous or bony tissue.
The most common are:
- Calcaneonavicular coalition: an abnormal connection between the calcaneus and the navicular.
- Talocalcaneal coalition: an abnormal connection between the talus and the calcaneus, which can significantly limit movement of the subtalar joint.
These connections may go unnoticed in the first years of life and show up as the coalition ossifies, usually in late childhood or adolescence. They can cause pain, stiffness, limited movement and repeated sprains.
2. Congenital and developmental conditions
Some bone or joint malformations can change the shape and movement of the foot from an early age. These include certain hindfoot deformities and abnormalities of bone alignment that need individual assessment.
3. Neuromuscular conditions and other causes
In certain patients, rigid flatfoot may be associated with neurological, muscular or joint disorders. Weakness, walking abnormalities, progressive deformities or other clinical signs may point to a different cause and call for further tests.
Treatment
Treatment must be tailored to the cause, the intensity of pain, the degree of stiffness, the patient’s age and any degenerative changes or associated deformities.
Conservative treatment
In patients with mild or moderate symptoms, non-surgical treatment may be started, including:
- Temporarily modifying the activities that cause pain.
- Adapting footwear and, in selected cases, insoles to improve comfort.
- Physiotherapy aimed at maintaining available movement and treating associated muscle spasm.
- Pain relief or anti-inflammatory medication when prescribed by the doctor.
These measures can relieve symptoms, although they do not necessarily correct the structural cause of the stiffness.
Surgical treatment
Surgery is considered when pain and functional limitation persist despite conservative treatment, or when the structural problem needs a specific correction.
Surgical options include the Evans–Mosca calcaneal lengthening osteotomy, the Cotton osteotomy, the Koutsogiannis osteotomy and, in selected cases, tibialis posterior transfer.
Correcting the associated deformity
When there is significant hindfoot valgus or a deformed flat foot, bone realignment procedures such as calcaneal osteotomies with titanium wedges may need to be added to improve foot mechanics and reduce overload.
Arthrodesis in selected cases
In very rigid deformities, with significant joint damage or when reconstructive techniques cannot achieve a satisfactory result, arthrodesis (joint fusion) may be considered. This option is reserved for specific situations, especially when there is advanced joint damage.
The aim of surgery is to relieve pain, improve function and achieve a stable, well-aligned foot, preserving joint movement whenever possible.
Flatfoot reconstruction with porous titanium wedges
Porous titanium wedges correct deformities using a structure designed to encourage bone to grow into the implant. Their mechanical properties and dimensional stability can help maintain the correction achieved during surgery.
Compared with autologous bone graft or allograft, porous titanium wedges have potential advantages: when used as a graft substitute they avoid the need to harvest bone from a donor site, and they eliminate the resorption problems of transplanted bone. However, biological integration and clinical results must be assessed according to the surgical technique, the type of deformity and the available evidence.
Dr. Corominas uses these techniques as part of individualised surgical planning, taking into account the patient’s age, foot anatomy, the size of the deformity and functional goals.
Outlook and recovery
Not all flat feet are the same. While flexible flatfoot is usually part of normal development, rigid flatfoot may be a sign of a structural problem that needs investigating.
A specialist assessment makes it possible to identify the cause, choose the right imaging tests and design treatment tailored to each child or adolescent, with the aim of relieving pain, preserving movement and supporting good long-term foot function.
Dr. Laura Corominas Francés has specialist experience in diagnosing and treating flatfoot in children and adolescents, including complex rigid flatfoot deformities and bone reconstruction techniques. Her clinical practice includes individualised surgical treatment of structural foot problems, with particular focus on reconstruction with porous titanium wedges, an alternative to bone graft in certain flatfoot correction procedures.
This page is for general information and does not replace an assessment by a specialist. If you are worried about your child's foot, talk to their paediatrician or book an appointment.