Adult acquired flatfoot deformity – fallen arches and flat feet treatments

Ross Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C.

Learning points about treatment

  • The posterior tibial tendon importance in maintaining the arch of the foot is seen by the problems created by the dysfunction or failure of the posterior tibial tendon. One problem is adult acquired flat foot.
  • Posterior tibial tendon injury or weakness causing pain that may precede flat feet is the discomfort or pain that runs just inside the bone of the ankle between the heel and the ankle.
  • People might have some pain standing on their tiptoes and got some weakness in that position as well.
  • In many people that come into our office, they will have “a little bit of flat foot,” and they are doing a lot of sports that are straining and overloading the deltoid ligament.

Discussion summary points of this article:

  • Adult acquired flatfoot deformity – fallen arches and flat feet treatments
  • The posterior tibial tendon connects the calf muscles to the arch of the foot. A lot of things can happen to a foot or a calf in this very vulnerable to injured area.
  • “I need somebody who knows about feet and understands Posterior tibial tendon dysfunction.”
  • Wear and tear injury does not happen in isolation. If your posterior tibialis tendon is frayed or damaged from years of sports, physically demanding work, or obesity, it is very likely that you have more issues than flat feet going on.
  • The conservative care treatments for flat feet, why they did not work for you.
    • RICE Therapy – Rest, Ice, compression, elevation.
    • NSAIDs nonsteroidal anti-inflammatories.
    • Physical therapy and exercise.
    • Arch support
  • What may work, what may not work for the treatment of posterior tibial tendon dysfunction stages I and II (flat foot).
  • Fusion of the midfoot surgery.
  • Posterior tibialis tendon? Spring ligament? Plantar fascia? What is the cause of your flat feet? Is it really ankle problems? A study puts into question the primary importance of the tibialis posterior tendon.
  • Did flat feet cause posterior tibial tendon dysfunction or did posterior tibial tendon dysfunction cause flat feet?
  • Did anyone discuss ligament damage with you? Introducing the ligament aspect of the plantar calcaneonavicular ligament or “spring ligament.”
  • “Failure to recognize an isolated spring ligament injury as the primary cause of a flatfoot deformity could lead to inappropriate operative management.”
  • “It is beneficial to confirm the presence of ligament tears before surgical exploration to avoid unnecessary dissection.”
  • Posterior tibial tendon insufficiency: which ligaments are involved?
  • It should be clear now that flat feet involve many ligaments. But how can you treat them all? Is it surgery?
  • The worse the condition, the more surgical options, but can non-surgical options still work?
  • How did we progress from shoe inserts to the triple fusion of the calcaneocuboid, talonavicular, and subtalar joints PLUS ankle fusion?
  • Stopping the degenerative path of flat feet with Prolotherapy and PRP regenerative medicine injections.
  • Treating the posterior tibialis tendon with Prolotherapy and PRP injections.
  • Research: The great incidence of tendon injuries and a failure rate of up to 25% of the available conservative treatments has made alternative biological approaches (Platelet Rich Plasma) “most interesting.”
  • Fixing damage to the posterior tibialis tendon with pro-inflammatory treatments.
  • Platelet Rich Plasma Therapy and Prolotherapy.

Adult acquired flatfoot deformity – fallen arches and flat feet treatments

There are many things that will cause adult-acquired flatfoot deformity. This article will focus on how adult-acquired flatfoot deformity is caused by structural damage to your supporting foot, ankle, and leg ligaments and tendons, with a focus on the posterior tibial tendon and the spring ligament. We will explore surgical, non-surgical conservative care, and regenerative medicine treatments.

If you are reading this article you probably do not need a description of what flat feet are, you can see it for yourself. The arch on the inside of your foot is flat and the sole of the footrests is on the ground. How did this happen? There could be many different factors. While obesity, diabetes, and genetic factors are important in the development of some cases of flat feet, we are going to discuss wear and tear damage and injury.

The posterior tibial tendon connects the calf muscles to the arch of the foot. A lot of things can happen to a foot or a calf in this very vulnerable to injured area.

If you are already seeking medical attention for problems of flat feet, it has probably already been explained to you that the main function of the posterior tibial tendon is to hold up the arch of the foot and support the foot when walking. When there is an injury to this tendon the arch is no longer supported. Injury to the posterior tibialis tendon can be acute or chronic wear and tear degenerative type injury.

If you have been injured in sport, a car accident, or a misstep or fall and you developed flat foot or flat feet, the acute injury cause makes a lot of sense to you. An obvious event occurred that damaged this tendon.

What are we seeing in this image?

Over time, the deltoid ligament which is the inside ligament portion of the ankle and holds it from rolling over on the inside will weaken. If you have some degree of a flat foot, you may find that when you walk, your ankle is in fact rolling inwards, or is in “overpronation.” So over decades of running or wear and tear, your foot is slowly stretching out not only the deltoid ligaments but also the posterior tibial tendon.

Ligaments are very important for bone to bone stability. Over time, the deltoid ligament which is the inside ligament portion of the ankle and holds it from rolling over on the inside will weaken. If you have some degree of flat foot, you may find that when you walk, your ankle is in fact rolling inwards, or is in "overpronation." So over decades of running or wear and tear, your foot is slowly stretching out not only the deltoid ligaments but also the posterior tibial tendon.

  • Ligaments are very important for bone-to-bone stability. Over time, the deltoid ligament which is the inside ligament portion of the ankle and holds it from rolling over on the inside will weaken. If you have some degree of a flat foot, you may find that when you walk, your ankle is in fact rolling inwards, or is in “overpronation.” So over decades of running or wear and tear, your foot is slowly stretching out not only the deltoid ligaments but also the posterior tibial tendon.
  • Tendons don’t like to be stretched out, they have a limited amount of ability to heal so when someone starts developing pain in this region our treatment recommendation is for Prolotherapy. A regenerative injection treatment. This treatment would not only be focused on the posterior tibial tendon but on the deltoid ligament complex as well. In some cases, Platelet-rich Plasma therapy may be offered. Both Prolotherapy and Platelet Rich Plasma treatments are explained below.
  • We typically need to perform 2 to 4 treatments to strengthen this area, if the patient is severely flat-footed, we may need 6 treatments.
  • The typical downtime is 4 to 6 days after each treatment. If the patient is a heavy runner we may ask them to lighten training or running for 1 – 2 weeks.

In this image, we see how many ligaments hold the foot and ankle complex together. The Posterior tibiofibular ligament and the deltoid ligament are featured.

“I need somebody who knows about feet”

“I need somebody who knows about feet” is the title of a November 2019 research paper published in the Journal of Foot and Ankle Research. (1) This paper strongly discusses the lack of understanding of Posterior tibial tendon dysfunction.

Here are the summary learning points. The opinions are the direct quotations of the researchers:

Research suggests that posterior tibial tendon dysfunction is poorly recognized and difficult to treat. When posterior tibial tendon dysfunction is diagnosed, the clinician is faced with a weak evidence base and guidelines for the common conservative treatments to guide their management.

Moreover, there are no current evidence-based guidelines for the conservative management of posterior tibial tendon dysfunction. . . Conservative treatments for posterior tibial tendon dysfunction are generally undertaken during early management. The most common are foot orthoses, exercises, bracing, lifestyle changes, and injections.

Quantitative evidence supporting conservative treatments for posterior tibial tendon dysfunction in relation to function, pain, and patient-reported outcome measures are reported in the literature. There is a paucity of qualitative research investigating the psychosocial (the mental aspect) impact of the common treatments for posterior tibial tendon dysfunction.”

What is being suggested is that poor treatment and confused understanding of posterior tibial tendon dysfunction will cause mental duress in patients who are not getting better. This may sound like an obvious treatment but these researchers are saying this aspect is not appreciated by the medical community.

Wear and tear injury does not happen in isolation. If your posterior tibialis tendon is frayed or damaged from years of sports, physically demanding work, or obesity, it is very likely that you have more issues than flat feet going on.

Chronic pain and injury will of course impact someone emotionally and mentally. This develops over time because the injury develops over time and as pointed out in the previous study, there are aspects of posterior tibial tendon dysfunction that are poorly understood. One aspect of this injury that should not be poorly understood is that wear and tear injury does not happen in isolation.

If your posterior tibialis tendon is frayed or damaged from years of sports, physically demanding work, or obesity, it is very likely that you have more issues than flat feet going on. In addition to experiencing pain in the lower legs where the tendon attaches to the calf muscle, the problems that you are encountering because of your flat feet may show up in your hips, ankles, or knees. What else is showing up? Probably a lot of inflammation in your feet. As you will see, and probably experienced first hand, the initial medical plan for people with flat feet discomfort is to manage pain and the functional loss with painkillers, anti-inflammatories, and shoe inserts. What you probably are also experiencing firsthand is that this is not working for you.

Doctors writing in the Journal of Family Medicine and Primary Care, (2) give a good outline of the paths of treatments a patient with flat feet can take. Here are their learning points:

  • Degenerative changes in the posterior tibial tendon will lead to pain and weakness and if not identified and treated will progress to deformity of the foot and degenerative changes in the surrounding joints.
  • Patients will complain of medial foot pain (pain near the arch), weakness, and a slowly progressive foot deformity. A “too many toes” sign (this is when you stand behind the patient and their foot is collapsing inward and forces the toes to point outward. You can see their toes from behind and it looks like they have “too many toes.”
  • Patients will be unable to perform a single heel raise test.
  • The optimal management of Posterior tibial tendon dysfunction may change based on the progression of deformity and stage of the disease. Early identification and prompt initiation of treatment can halt the progression of the disease.

The doctors then go about describing the various stages of the disease and the treatment options available to patients. These are the general recommendations for treatment, not necessarily our type of treatment.

Stage I disease

  • A walking cast or CAM (Controlled Ankle Motion) boot can be used to immobilize the foot. If this brings relief, the patient can have shoe inserts or modifications, orthotics or an ankle-foot orthosis (AFO) fitted.
  • Physiotherapy for Achilles tendon stretching and tibialis posterior strengthening along with nonsteroidal anti-inflammatories can also help.
  • Up to 4 months of nonoperative treatment should be tried; if there is no improvement after this period, a tendon synovectomy or debridement may be indicated.

We are going to stop here to discuss some of these options. 

  • Walking boots can be helpful in some cases for a limited amount of time. Sometimes this is especially helpful for the patient who has a hard time “slowing things down” and does not allow their injury to heal.
  • Physical therapy, NSAIDs may not be effective for you. See below why these treatments were not as effective as you may have hoped for.
  • Tendon synovectomy or Endoscopic Debridement is a surgery that may have been explained to you that will scrape away inflamed tissue off the tendon.

We are going to get back to these outlines but Stage 1 is the dividing line between conservative treatments and surgical intervention. If conservative care does not work, Stage II disease comes with a more aggressive surgical recommendation.

The conservative care treatments for flat feet, why they did not work for you

Some people get benefit from conservative care treatment. Some people do not. If you are reading this article it is very likely that you did not get relief from your foot problems with these treatments. What is surprising to some patients we see is that they tell us that they tried many of these treatments on their own, and then, when the problems and symptoms they were having became more significant, they received the same treatment recommendations from their health care clinician. When they told the clinician that they had already tried these treatments, many simply received stronger doses or recommendations to longer periods of rest and immobilization or “better” orthotics.

Let’s go through the roll call of conservative treatments.

RICE Therapy – Rest, Ice, compression, elevation.

  • The idea is that problems of flat feet are made worse by inflammation in the arch and the posterior tibialis tendon. The recommendation to Rest, Ice, Compression, and Elevates seeks to tackle the inflammation problem without medication.

NSAIDs nonsteroidal anti-inflammatories

  • NSAIDs nonsteroidal anti-inflammatories – there is a good chance that if these medicines did not help, they are hurting you.  Why the NSAIDs did not help you and may have made your situation worse is covered in our article When NSAIDs make the pain worse

Physical therapy and exercise

  • Physical therapy and exercise. A September 2018 report in the British Medical Journal Open Sport and Exercise Medicine (3) from the University of Queensland concluded with this statement:
    • “Based on the limited available literature, it appears that local strengthening exercises provide some benefit in Posterior tibialis tendon dysfunction, and eccentric exercises (a downward motion with a weight load – such as a heel lift exercise – the motion of returning the heel to the floor would be considered eccentric exercises) may be superior for improving pain, disability and self-reported overall foot function than concentric exercises (in the same heel lift exercise – this would be the motion of standing on your toes and elevating you heel upwards) and foot orthoses and stretching alone.”
    • “No recommendations can currently be made regarding optimal exercise prescription based on published clinical trials.”

Arch support

  • Arch support: The typical treatment for pain from fallen arches is an arch insert. While many people experience dramatic pain relief from this, others continue to suffer from chronic achy feet despite the arch support. The long-term problem with this approach is that it does not strengthen the weak arch ligaments that may be at the root of the problem.

What may work, what may not work for the treatment of posterior tibial tendon dysfunction stages I and II (flat foot)

A February 2021 paper in the journal Clinical Rehabilitation (19) investigated whether orthotic treatment is effective for the treatment of posterior tibial tendon dysfunction stages I and II (flat foot).To achieve the summary results, the investigators reviewed previously published medical material.  Four random-control trial articles and 186 subjects were included.

  • Three different types of conservative treatment were used in the studies:
    • foot/ankle-foot orthoses,
    • footwear and stretching /strengthening exercises.
  • Foot orthoses, together with exercise programs, seemed to improve the effect of orthotic treatment. Foot orthoses with personalized internal longitudinal arch support were more effective than flat insoles or standard treatments in reducing pain.

Conclusions: The use of orthotic treatment may be effective in reducing pain in the early stages of posterior tibial tendon dysfunction.

A July 2021 study in the International Journal of Environmental Research and Public Health (20) also reviewed previously published studies and wrote this: “Adult flatfoot leads to injury and decreased quality of life. The most widely applied noninvasive approaches are wearing foot orthoses or exercising. Both interventions raise controversy about reducing pain and neutralizing foot posture. Both exercise and foot orthoses can reduce pain but not realign foot posture. Exercise alone or combined with foot orthoses showed a better effect on adult flatfoot than only wearing foot orthoses.”

But, as it became apparent that these treatments were failing, the patients then tell us that surgery was discussed on a more urgent basis. However, the surgery option for many of these people presented a somewhat concerning option. It is a concerning option for surgeons as well, listen:

Surgical procedures are available; however, these require a lengthy recovery, and therefore patients should be advised accordingly”

Doctors at the University of Rochester wrote in the journal The Medical Clinics of North America:(4) “The mainstay of nonoperative treatment (for adult acquired flatfoot deformity) is nonsteroidal anti-inflammatory drugs, weight loss, and orthotic insoles or brace use. The goals of therapy are to provide relief of symptoms and prevent the progression of the deformity. If nonoperative management fails, a variety of surgical procedures are available; however, these require a lengthy recovery, and therefore patients should be advised accordingly.”

“Long recovery time” is not what an active person wants to hear.

Some people do well with surgery. A January 2020 study in the journal The Orthopedic Clinics of North America (5) says: “Reconstruction of the flexible adult-acquired flatfoot deformity is controversial, and numerous procedures are frequently used in combination, including flexor digitorum longus transfer, medializing calcaneal osteotomy (MCO), heel cord lengthening/gastrocnemius recession, lateral column lengthening (LCL), Cotton osteotomy or first tarsometatarsal fusion, and spring ligament reconstruction.” And that, “patients have significant improvements after operative treatment of flexible adult-acquired flatfoot deformity.”

Better to get an orthotic than “debilitating surgery”? Surgery for flat feet does remain controversial.

Surgery for flat feet does remain controversial. Not that it won’t work, but rather that the surgery can make the problem worse. We discuss this further below.

Fusion of the midfoot surgery

In the medical journal, Clinical Biomechanics (6) doctors and researchers wrote:

“Surgical treatment of adult-acquired flatfoot deformity can involve arthrodesis (fusion) of the midfoot to stabilize the medial column (Note: This is the area at the base of the big toe. A fusion in this area involves removing the joints between the navicular, medial cuneiform, and first metatarsal).”

Note: Some people do very well with this surgery. Not all. Let’s get back to the study:

“We advocate caution regarding fusions of the naviculocuneiform joint (at the base of the big toe) as it leads to increased stresses across the Spring ligament and therefore accelerates the development of planovalgus (a flattened arch and a rolled in ankle appearance).”

Let’s look now at another January 2020 study, this one published in the journal Clinics in Podiatric Medicine and Surgery. (7)

“The adult acquired flatfoot deformity resulting from posterior tibial tendon dysfunction is the result of rupture of the posterior tibial tendon as well as key ligaments of the ankle and hindfoot. Kinematic studies have verified certain levels of deformity causing hindfoot eversion (the motion of turning “inside out.”), lowering of the medial longitudinal arch and forefoot abduction. The condition is progressive and left untreated will cause significant disability. Bracing with ankle-foot orthoses has shown promising results in arresting the progression of the deformity and avoiding debilitating surgery. Various types of ankle-foot orthoses have been studied in terms of effects on gait as well as efficacy in treatment.”

But is a brace healing your problem or providing artificial stability? We believe it is better to provide that stability by treating and strengthening the ligament and tendons.

What are we seeing in this image? The components of the foot arch complex.

The focus of this image is plantar aponeurosis or plantar fascia. Its primary function is to stabilize the arch of the foot, especially when walking.

Posterior tibialis tendon? Spring ligament? Plantar fascia? What is the cause of your flat feet? Is it really ankle problems? A study puts into question the primary importance of the tibialis posterior tendon.

In our opinion, nothing gives better evidence that your problems of flat feet can be coming from multi-factorial issues than the debate in the medical community as to what causes adult acquired flatfoot deformity and why certain conservative care treatments, like those mentioned above, are not helping.

A February 2019 study published in the Journal of Biomechanics (8) by medical university researchers in Spain gives the scenario that fallen arches and flat feet are the failures of many structures. The results of their research show that plantar fascia is the main tissue that prevents arch elongation (flattening), while the spring ligament mainly reduces foot pronation (turning inward, especially common in runners with flat feet). Long and short plantar ligaments play a secondary role in this process.

The stress increment on both plantar fascia and spring ligament when one of two fails suggests that these tissues complement each other. These findings support the theory that regards the tibialis posterior tendon as a secondary actor in arch maintenance, compared with the plantar fascia and the spring ligament.

This 2019 study puts into question the primary importance of the tibialis posterior tendon.

Did flat feet cause posterior tibial tendon dysfunction or did posterior tibial tendon dysfunction cause flat feet?

Often a patient will come into our clinic and tell us: “My surgeon tells me that I have posterior tibialis tendon dysfunction, When I asked, “what does this mean?” My doctor told me: “You flat feet are getting worse. He really did not need to tell me that my problem was getting worse. I was sitting in the surgeon’s office because of it. My flat foot problem has been going on for some time. The more I walk, the more pain I have. I have to use crutches, boots, and anti-inflammatories. To stay active I have taken to biking everywhere. That hurts now too. I asked my surgeon, what is the possibility of success with the surgery?”

Some people may have great success with tibialis posterior tendon surgery. Some people will not. Who are these people? The people who tibialis posterior tendon dysfunction may not have been a problem at all.

Often we will get an email or a patient will tell us: “Initially my doctor thought it was tibialis posterior tendon dysfunction. He was not sure. I went to another specialist, she told me that she believed it was Tarsal Tunnel Syndrome and that I should explore other options beyond surgery. I am here to see what you think.”

In a 2004 study, the role of the tibialis posterior tendon was also questioned in a “what came first scenario.” Did flat feet cause posterior tibialis tendon dysfunction or did posterior tibialis tendon dysfunction cause flat feet? This is what researchers at  Drexel University wrote about in the journal Clinical Biomechanics (9).

  • Posterior tibialis tendon dysfunction, they suggest, causes an abnormal loading of the foot’s medial structures. This may be the reason that posterior tibialis tendon dysfunction leads to an acquired flatfoot deformity. Conversely, flatfoot deformity may be a predisposing factor in the onset of posterior tibialis tendon dysfunction.”

What is causing what? 

As we point out over and over again, problems of the joints, ligaments, and tendons, are not typically a problem that sits in isolation, and if you treat this one problem, “everything,” will be fixed. This is usually not the case.

Let’s look at a 2015 paper from foot specialists in Switzerland. They published these opinions in the Journal of Foot and Ankle Research. (10) The title of the paper: “Non-surgical treatment of pain associated with posterior tibial tendon dysfunction.” The hypothesis was what could benefit posterior tibial tendon dysfunction? Foot inserts? Physical Therapy? Exercise? This research has not yet published its final findings,(11) but here is an insight:

“Symptoms associated with pes planovalgus or flat feet occur frequently, even though some people with a flatfoot deformity remain asymptomatic. (Symptom-free). Pes planovalgus (Flat feet) is proposed to be associated with foot/ankle pain and poor function. Concurrently, the multifactorial weakness of the tibialis posterior muscle and its tendon can lead to a flattening of the longitudinal arch of the foot.”

Note: Flat feet are associated with foot and ankle pain and poor function. The problem is beyond the foot and impacts the ankle.

“Less severe cases (of flat feet) at an early stage are eligible for non-surgical treatment and foot orthoses are considered to be the first-line approach. Furthermore, strengthening of arch and ankle stabilizing muscles are thought to contribute to active compensation of the deformity leading to stress relief of soft tissue structures.”

Note: If you strengthen the stabilizing muscles of the ankle and arch, you may have successful treatment. How do we do this? By addressing the tendon attachments of the muscle to the ankle and foot bones and the ligaments which connect the bones to the bones to create stability in the ankle and foot.

Did anyone discuss ligament damage with you? Introducing the ligament aspect of the plantar calcaneonavicular ligament or “spring ligament.”

Although the skeletal structure is important to arch support, without the ligaments, the arches would collapse. The plantar ligaments (ligaments on the bottom of the foot), which are stronger and larger than dorsal ligaments (ligaments on top of the foot), tie the inferior edges of the bones together. The most important ligament in the maintenance of the medial longitudinal arch is the plantar calcaneonavicular or spring ligament.

The plantar calcaneonavicular ligament passes from the lower surface of the calcaneus (heel bone) to the lower surface of the navicular bone (located just above the arch). This ligament resists the downward movement of the head of the talus, supporting the highest part of the arch, and is responsible for some of the elasticity of the arch. This ligament is also known as the spring ligament.

As we mentioned at the top of this article, problems of flat feet do not occur in isolation, they are typically the composite of many factors. Research is telling us this and our own clinical observation bear this out. Your problems with flat feet are more than a problem with the arch of your foot.

“Failure to recognize an isolated spring ligament injury as the primary cause of a flatfoot deformity could lead to inappropriate operative management.”

In the journal Foot and Ankle International, (12) a study lead by Dr. J.D Orr at the William Beaumont Army Medical Center made this suggestion:

“Adult-acquired flatfoot deformity is usually secondary to tibialis posterior tendon failure but in rare cases may be secondary to isolated spring ligament injury without tibialis posterior tendon abnormality. This unique clinical entity should be considered in patients who present with flatfoot deformities.  . . Failure to recognize an isolated spring ligament injury as the primary cause of a flatfoot deformity could lead to inappropriate operative management.”

As we have discussed in this article, the challenges of surgical treatment of flat foot deformity are many, we have introduced you to surgical studies that outline these challenges, people do benefit from surgery, but there are challenges including the problem of “additional dissection” or additional cutting into the tissue when it may not be needed.

“It is beneficial to confirm the presence of ligament tears before surgical exploration to avoid unnecessary dissection”

At the Department of Orthopaedics and Traumatology, North District Hospital in China, doctors wrote in the journal Arthroscopy Techniques (13) of the challenges of surgical repair:

“A tear of the spring ligament is frequently associated with posterior tibial tendon dysfunction. Repair of the damaged spring ligament is an important component of surgical reconstruction in the treatment of posterior tibial tendon dysfunction because it is a major anatomic contributor to the integrity of the medial longitudinal arch, particularly if the dynamic support of the posterior tibial tendon is compromised.

    • Extensive dissection is required for exposure and repair of the ligament because it is a deep-seated structure.
    • It is beneficial to confirm the presence of ligament tears before surgical exploration to avoid unnecessary dissection.
    • Preoperative magnetic resonance imaging and ultrasound studies have moderate sensitivity (not reliable) in the detection of these tears.”

Posterior tibial tendon insufficiency: which ligaments are involved?

The above is the title of a paper from doctors at the Hospital for Special Surgery published in the journal Foot and Ankle International,(14) let’s go to the learning points of this study:

  • The challenges manifested in posterior tibial tendon insufficiency are not limited to the posterior tibial tendon.
  • The purpose of this observational study was to identify the pattern of ligament involvement in patients’ posterior tibial tendon insufficiency.
  • Ligament involvement is extensive in PTTI, and the spring ligament complex is the most frequently affected. Because ligament pathology in PTTI is nearly as common as posterior tibial tendinopathy, treatment should seek to protect or prevent progressive failure of these ligaments.
    • This includes the superomedial and inferomedial components of the spring ligament complex
    • talocalcaneal interosseous ligament, the primary connective link between the ankle and the heel.
    • long and short plantar ligaments, the ligaments of the arch.
    • plantar fascia,
    • deltoid ligament provides stability to the ankle’s tibiotalar joint, and manage stress forces between tibia and tarsus (ankle)
    • plantar naviculocuneiform ligament, and
    • tarsometatarsal ligaments. (Both of these ligaments work within the long bones of the toes).

It should be clear now that flat feet involve many ligaments. But how can you treat them all? Is it surgery?


The worse the condition, the more surgical options, but can non-surgical options still work?

We are going to return to the above research from the Journal of Family Medicine and Primary Care (1) to examine more surgical options and then to begin presenting our case for regenerative medicine techniques.

In the research we are citing, the doctors write about Stage II, III, and IV treatment challenges:

  • Nonoperative methods can still be tried at Stage II and include walking cast, CAM boots, or orthotics. These interventions often prove to be ineffective and surgical treatment is typically carried out in Stage II of the disease.
  • A surgical recommendation is made because the foot or bone deformity is still correctable and joint degeneration has not occurred, allowing for better joint alignment and possibly avoiding joint fusion.
  • A variety of surgical methods have been described, and these normally include bony procedures along with soft tissue reconstruction and tendon transfers.
    • Traditionally, this would consist of a combination of:
      • calcaneal osteotomy (heel bone shaving), posterior tibial tendon excision (removal or repair of parts of the tendon),
      • flexor digitorum longus transfer, in the journal Podiatry Today (15) March 2, 2017, Dr. Douglas H. Richie, Jr. wrote: “Despite the dismal results of transferring the flexor digitorum longus to the navicular in hopes of replacing the ruptured posterior tibial tendon, surgeons continued to embrace this concept as an adjunctive procedure to other approaches in adult-acquired flatfoot surgical correction, including a medializing calcaneal osteotomy and lateral column lengthening. . . It is quite remarkable that a procedure that by itself showed no benefit in adult-acquired flatfoot surgery continued to be a standard of operative care for over 40 years”
      • and Achilles tendon lengthening (here doctors will try to stretch the Achilles tendon to take tension off the knee and arch).
  • When the disease progresses to Stage III and Stage IV there is ankle joint involvement.
    • Here doctors should work on pain management. Surgical intervention at these stages will involve multiple bony procedures such as osteotomies and arthrodesis. In Stage III typically a triple arthrodesis (fusion) of the calcaneocuboid, talonavicular, and subtalar joints is undertaken, whereas in Stage IV an ankle joint fusion is performed, in addition to a triple arthrodesis.

The complexity of the ligaments in contributing to flat foot deformity

In the most current study, researchers at the University of Arizona wrote in January 2022 in the Journal of Orthopaedic Research (21) about the complexity of the ligament structure in flat foot deformity and that while one ligament injury may not cause a foot collapse, a combination of ligament weakness or damage can. It may not take that much damage. Here is what they wrote:

“The contribution of each of the ligaments in preventing the arch loss, hindfoot valgus, and forefoot abduction seen in progressive collapsing foot deformity have not been well characterized. An improved understanding of the individual ligament contributions to the deformity would aid in selecting among available treatments, optimizing current surgical techniques, and developing new ones.

In this study, we evaluated the contribution of each ligament to the maintenance of foot alignment. . . Our findings show that the failure of any one ligament did not immediately lead to deformity, but that combined failure of only a few (the plantar fascia, long plantar, short plantar, deltoid, and spring ligaments) could lead to significant deformity.

The plantar fascia, deltoid, and spring ligaments were primarily responsible for the prevention of arch collapse, hindfoot valgus, and forefoot abduction, respectively. Moreover, to produce deformity, a considerable amount of attenuation (damage) in the spring, tibiocalcaneal, interosseous talocalcaneal, plantar naviculocuneiform, and first plantar tarsometatarsal ligaments, but only a small amount (of damage) in the plantar fascia, long plantar, and short plantar ligaments were needed. The results of this study suggest that the ability of a ligament to prevent deformity may not correlate with its attenuation (damage) in a collapsed foot.

In other words, it could be a lot of damage, it could be minor damage to the ligament that can cause flat foot deformity. To further clarify this, Hamed Malakoutikhah of the Department of Aerospace and Mechanical Engineering, University of Arizona, the lead researcher of this paper sent us this: “We actually found that the plantar fascia, long plantar, short plantar, deltoid, and spring ligaments have the most contribution to maintaining the arch and foot alignment, while other ligaments such as the interosseous talocalcaneal, plantar naviculocuneiform, and first plantar tarsometatarsal ligaments have only a minor contribution. Additionally, we found that some ligaments—such as the spring, interosseous talocalcaneal, plantar naviculocuneiform, and first plantar tarsometatarsal ligaments—were damaged more severely during the flatfoot process, whereas other ligaments—such as the plantar fascia, long plantar, and short plantar ligaments—were less severely damaged. This surprising result suggests that the ability of a ligament to prevent deformity may not always correlate with its attenuation (damage) in a flatfoot.

For example, the plantar fascia, long, and short plantar ligaments contributed most to maintaining the arch, though they experienced minor damage. On the other hand, the interosseous talocalcaneal, plantar naviculocuneiform, and first plantar tarsometatarsal ligaments contributed very little to maintaining the arch but are much more severely damaged. More accurately, we can say “In a flatfoot, some ligaments (the spring, interosseous talocalcaneal, plantar naviculocuneiform, and first plantar tarsometatarsal ligaments) are severely damaged, while some (the plantar fascia, long plantar, and short plantar ligaments) are only mildly damaged.”

How did we progress from shoe inserts to the triple fusion of the calcaneocuboid, talonavicular, and subtalar joints PLUS ankle fusion?

It all started when you began noticing pain in the arch of your foot. You tried to manage this yourself, it got to be too much for you to manage on your own and you made a trip to the doctor. There the same treatments you were doing yourself, stretching the arch, taking anti-inflammatories, ICE, resting, taping, shoe inserts, were re-recommended to you. Maybe you were given strong medications, maybe you were sent to physical therapy, whatever happened, if you have made it to this point in our article, none of these treatments prevented the foot destruction you were suffering from.

Worse, the destruction of your foot is now extending from top to hip and possibly low back. When the ligaments that support the inside of the foot, especially the calcaneonavicular ligament, are damaged, the arch pain will increase. Eventually, the posterior tibialis tendon in the knee must help support the arch. This tendon eventually weakens, resulting in knee pain added to the original foot pain, as the arch continues to collapse.

Because the arch and the knee can no longer elevate the foot, the entire limb must be raised during a step, putting additional strain on the hip. The spring in the foot and the efficiency of the gait are drastically reduced due to the collapsed arch. This requires more energy from the foot, resulting in further deterioration of the medial arch. The more severe the collapse of the arch, the greater the likelihood of pain. The deterioration cycle will continue until something is done to support the arch. For many people, this is the triple fusion of the calcaneocuboid, talonavicular, and subtalar joints PLUS ankle fusion.

Stopping the degenerative path of flat feet with Prolotherapy and PRP regenerative medicine injections.

Prolotherapy is the treatment that can make the most sense for a fallen arch due to weak ligaments. Prolotherapy is an injection technique utilizing simple sugar or dextrose. Prolotherapy injections into the fibro-osseous junctions of the plantar fascia and calcaneonavicular ligament, which supports the arch, will strengthen this area. If the condition is diagnosed early on, the ligaments can be strengthened to support the arch. If the process has gone on for years, arch support may be needed in addition to Prolotherapy. But even in the latter case, Prolotherapy can eliminate chronic arch pain.

Prolotherapy is the injection of simple sugar, dextrose. The goal of the treatment is ligament repair. This is achieved by injecting the dextrose at the spot of ligament attachments that connect bones.

Treating the posterior tibialis tendon with Prolotherapy and PRP injections

The problems of treating tendon dysfunction with conservative care and surgical options, as we outlined above, are challenging. It is so challenging that surgeons published these observations in the  Journal of Experimental Orthopaedics. (16) December 2018.

  • Patients and health care providers have a choice to treat tendon problems with multiple non-invasive (non-surgery) and tendon-invasive (surgery) methods.
  • When traditional non-invasive treatments fail, the injections of platelet-rich plasma autologous blood (we will get to this below) or cortisone have become increasingly favored. However, there is little scientific evidence from human studies supporting injection treatment.
  • As the last resort, open or arthroscopic surgery to the tendon, or surgery to the tendon and surrounding soft tissue are employed even though these also show varying results.

Research: The great incidence of tendon injuries and a failure rate of up to 25% of the available conservative treatments has made alternative biological approaches (Platelet Rich Plasma) “most interesting.”

A fascinating part of this research is the investigators suggesting that: “The study of the microenvironment of tendinopathy is a key factor in improving tendon healing.” What is the microenvironment of tendinopathy? INFLAMMATION

Listen to what the researchers suggest, it will give you an understanding of how to heal by getting rid of anti-inflammatory medications.

  • “An alternative anti-inflammatory and immunomodulatory (suppressing the immune response, i.e., inflammation) approach that replaces the traditional anti-inflammatory modalities (i.e. NSAIDs) may provide another potential opportunity in the treatment of chronic tendinopathies.”

The research shows that even in cases of tendinosis, where it is thought that no inflammation is occurring, there is still inflammatory cellular activity. IN OTHER WORDS – your tendon is waiting for the inflammation to start up again and do its repair and there is a “skeleton crew,” of cellular communicators waiting for signals. Waiting for signals as we will see below is an important part of the tendons rebooting its healing cycle.

Fixing damage to the posterior tibialis tendon with pro-inflammatory treatments

Rebooting the inflammatory process means getting blood flow and healing factors back into the damaged area. This means a change of thinking from anti-inflammatory to PRO-inflammatory treatments.

The best way in our opinion to show you how pro-inflammatory treatments heal where anti-inflammatory treatments do not heal is in the research making a direct comparison.

A multi-national team of researchers including those from Rutgers University, Virginia College of Osteopathic Medicine, and the University Regensburg Medical Centre in Germany tested the effects of Prolotherapy on tenocytes repair (tendon cells). Published in the journal Clinical Orthopaedics and Related Research(17) what the team was looking for was how did Prolotherapy injections change the immune system’s response to a difficult-to-heal tendon injury.

These are the highlights:

  • Prolotherapy injections changed the cellular metabolic activity to a healing, regenerative environment in the tendon cells.
  • Prolotherapy activated RNA expression. The healing phase of soft tissue injury starts spontaneously after the tendon injury. Healing occurs in three phases: inflammation, proliferation, and maturation. RNA expression is the communication changes in genes (remember the gene expression from above)  that coordinate the beginning and end of these three cycles of the healing and injury repair process.
  • Activated Protein secretion – the process of rebuilding. For a fascinating look at this subject please see our article on Extracellular matrix in osteoarthritis and joint healing.
  • Cell migration. The ability of healing cells to get to the site of an injury, and the denial of damaging inflammatory factors from reaching the same site.

In our own published research, we reported in the Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders, (18) we reported that the consensus is growing regarding the effectiveness of dextrose Prolotherapy as an alternative to surgery for patients with chronic tendinopathy who have persistent pain despite appropriate rehabilitative exercise.

Platelet Rich Plasma Therapy and Prolotherapy

Platelet Rich Plasma therapy (PRP) can be added to the traditional Prolotherapy solution to expedite the process, in specific cases.

  • PRP treatment re-introduces your own concentrated blood platelets into areas of chronic tendinopathy
  • Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma.
  • The procedure and preparation of therapeutic doses of growth factors consisting of an autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.)
  • In our clinic, patients are generally seen every 4-6 weeks. Typically three to six visits are necessary per area.

Below is a pro-inflammatory treatment demonstration of Prolotherapy combined with PRP treatments. This simple treatment brings pro-inflammatory factors into the damaged area to stimulate healing. The research is below.

A patient’s fallen arch and posterior tibial tendon graft from previous surgery is examined

We use high-resolution ultrasound to look at all forms of joint instability. In this case, we are looking at the joints of the medial arch.

  • At 0:28 Dr. Hauser describes an ultrasound of a patient who had surgery and a posterior tibial tendon graft from a cadaver. The patient had suffered an injury that caused their posterior tibial tendon to snap.
  • At 0:50. The patient is in our office because the surgery did not help them. The patient still had medial arch pain. We suspected the posterior tibial tendon graft because that tendon or graft is supposed to stabilize the arch of the foot.
  • At 1:13. Dr. Hauser describes continued problems with the arch because many times the other supportive structures of the arch hold together the subtalar joint. The subtalar joint is made up of the talus and calcaneus (ankle and heel). The plantar calcaneonavicular ligament (or spring ligament, sometimes called the spring ligament complex) connects the calcaneus with the navicular bone. (The connection between heel and toes that includes the arch). Problems with the posterior tibial tendon can be linked to laxity or weakness in the spring ligament complex.
  • At 1:45. An examination and ultrasound comparison of the patient’s ultrasound of the normal posterior tibial tendon graft.
  • At 2:05. When people have this posterior tibial tendon graft and they do not address or treat problems of the ligaments, the surgery will typically not succeed in meeting the patient’s goals. The surgical failure revolves around the posterior tibial tendon graft’s inability to support the arch by itself. It needs the help of supportive ligaments.
  • At 2:20 Treatments we gave the patient.
    • We put him in arch support as in this case this is where orthotics could help.
    • We started Prolotherapy injections on the medial side. When someone has a collapse of the arch, it is not just the spring ligament complex that is involved. It also involves the deltoid ligament which is the main ligament on the inside ankle joint or medial ankle joint.
  • Depending on the case, it can take 3 to 8 treatments to stabilize the medial side ankle and foot – not surgically.

Recap and a summary of treatments

In our 29 plus years of helping people with tendon injuries, we have found Prolotherapy and PRP treatments to be effective in helping these people’s goals of getting back to sports or work. The article you have just read is based on our years of experience in treating thousands and thousands of patients. The way we offer treatment is not how you may find this treatment offered at other clinics.

To recap: The medial arch is supported by fascia and ligaments. As previously explained, ligaments maintain proper bone alignment. Loose ligaments allow the bones to shift, resulting in chronic pain. The main supporting structure is the plantar fascia, also known as the plantar aponeurosis. The plantar fascia is essentially a strong, superficially placed ligament that extends in the middle part of the foot from the calcaneus to the toes. Another important structure is the plantar calcaneonavicular ligament which passes from the lower surface of the calcaneus to the lower surface of the navicular bone. This ligament resists the downward movement of the head of the talus, supporting the highest part of the arch, and is responsible for some of the elasticity of the arch. This ligament is also known as the spring ligament. An arch support insert is a typical treatment for a fallen arch. Many people experience dramatic pain relief, while others continue to suffer from chronic achy feet. Prolotherapy is the treatment that makes the most sense for a fallen arch due to weak ligaments. Prolotherapy injections into the fibro-osseous junctions of the plantar fascia and calcaneonavicular ligament, which supports the arch, will strengthen this area. If the condition is diagnosed early on, the ligaments can be strengthened to support the arch. If the process has gone on for years, arch support may be needed in addition to Prolotherapy.

If you have questions about your knee pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.

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This article was updated January 25, 2022

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