Home The Book Dr Articles Products Message Boards Journal Articles Search Our Surveys Surgery ESWT Dr Messages Find Good Drs video

Pes planus reconstruction

Posted by wendyn on 8/31/00 at 20:36 (026850)

Dr B and Dr Z....

I have pes planus (bilaterally), forefoot varus, an external tibial torsion on my right, TTS (both feet), history of PF, and according to Xrays and exam, gastroc equinus contracture and I think it was called a dorsolateral sublaxation (I still don't really understand what that is). I know my feet pronate but I don't know how much.

I am having an MRI October 2. I've had 2 nerve conduction tests, the last one was 100% normal. I've had 3 bone scans - none of them conclusive for much other than PF. Blood work was fine except low B12.

My foot and ankle surgeon (orthapedic surgeon) has mentioned the possibility of 'pes planus reconstruction' - my feet have been getting flatter since I was 11. I had bunion surgery for a dorsal bunion (right foot) when I was 22 (I'm 31 now) and I've had 3 pairs of custom orthotics that I've been unable to tolerate. I currently live in Birks.

I am unable to run or walk for exercise. I have had some trouble biking - but sometimes I get away with it. I can't do aerobics, or walk very fast. Standing for long periods is difficult. My overall health otherwise is very good.

What can you tell me about what's happening to me and can you provide information about pes planus reconstruction?

Anyone with any info is welcome to respond...I need all the help I can get!

Re: Pes planus reconstruction

Dr. Zuckerman on 8/31/00 at 22:16 (026855)

This is a very complex and long post-op healing type surgery. The purpose is to control the abnormal motion ( pronation in your foot..
Now how to do this is one of the question that:

You may need a lengthing of the gastronenius muscles.
A repositioning of the posterior tibial tendon.
Repostioning of the heel bone.
You need fusion of some of the subtalar joint bone.

I have a fellowship trained associate that has the training to do this type of surgery. It is very patient specific. You want to make sure that your foot and ankle surgeon doesn't just do one procedure, but instead looks at the entire lower extremity including the gastronemius and the ankle joint. So the surgery will and should vary form pateint to patient.

Re: Pes planus reconstruction

Dr. Biehler on 8/31/00 at 22:31 (026859)

When a person has ligamentus laxity ( you may or may not have this) it allows their bones to move farther in the joints than normal. In children this can give them very flat feet as opposed to being born with their bones making their feet flat. This perdisposes them to bunnions at an early age. If you have forefoot varus, this means with your foot in subtaylor neutral ( the normal alinement of bones while standing) you have an arch but the front of your foot would be slanting at an angle. When your arch colapses the forefoot rests on the ground. When this happens your foot is pronated and that is called pes plannus. In this position the ligaments are at their laxest in the foot which lets the bones spread out and in some theories, this puts the most tension on the plantar fasia as it holds the foot together.With the foot in this position it also has the tarsal tunnel fully streched out and by now has rendered the posterior tibial tendon almost worthless. With orthotics the problem is usually trying to correct everything right away ( a bad idea). I find that an acomadative orthotic with sight arch support and a slight varus post under the forefoot has helped some people alot. In reconstructive surgery they may try to put a plug in the subtaylor joint to keep it from pronating then tighten up the posterior tibial tendon or rearainge other tendons. Either way you are going to need a good orthotic. Dr. Biehler

Re: Pes planus reconstruction

wendyn on 8/31/00 at 22:50 (026861)

Thank you both for such detailed, informative (and fast)replies!

I agree that I need orthotics, so far I've been unable to find any I can wear. I will try another pair depending on what the MRI shows and what the surgeon says. Right now, the problem is that I cannot tolerate a shoe rubbing by my inner ankle (the tarsal tunnel spot). This makes it impossible for me to wear anything other than Birks. I do wear a running shoe with a Birk insert at the gym, but for no more than an hour at a time.

Dr B - I was also told I have a hyper mobile medial column (?) which I think means the joints in my feet move more than they should. I think a lot of the pain I have comes from my post tib tendon - what do you mean when you say 'it renders the post tib tendon pretty much useless'?

All right, so if I were to undergo this type of surgery at my age - what would be the likely outcome? I know you can't predict the future -but what do things look like with AND with out the surgery. Would I be able to hike, bike, go for long walks? Would it reduce the pain? Would it be good for a few years and then just fall apart? If I don't have the surgery, is it likely that things will continue to get worse? How much worse? I'm not looking to run marathons....I just would like some semblance of a normal life.

Re: Pes planus reconstruction

Dr. Biehler on 9/01/00 at 07:20 (026866)

The posterior tendon is what pulls and keeps the arch up. In a severly pes planus foot this has been streched out over the years and all the ligments and muscles in the foot have adapted. There are different surgeries and I think alot of people have been happy with the results. My point is that since your foot has adapted to its position, any orthotic must offer very slight correction to start with and should be comfortable. Even after surgery ( if that is the path you take) you will need an orthotic to help the posterior tendon suport the arch. Dr. Biehler

Re: Pes planus reconstruction

wendyn on 9/01/00 at 07:39 (026870)

Thank you!

What you are saying makes sense. This is probably also why I had such major problems from orthotics #2 - a rigid (very arched) pair that eventually almost crippled me.

Your tendon explanation sounds very similar to what I was told when I was 11 - for about a year my foot flopped around and I walked on the outside of it a lot. I must have done something significant to the tendon then.

Re: Pes planus reconstruction

Dr. Zuckerman on 8/31/00 at 22:16 (026855)

This is a very complex and long post-op healing type surgery. The purpose is to control the abnormal motion ( pronation in your foot..
Now how to do this is one of the question that:

You may need a lengthing of the gastronenius muscles.
A repositioning of the posterior tibial tendon.
Repostioning of the heel bone.
You need fusion of some of the subtalar joint bone.

I have a fellowship trained associate that has the training to do this type of surgery. It is very patient specific. You want to make sure that your foot and ankle surgeon doesn't just do one procedure, but instead looks at the entire lower extremity including the gastronemius and the ankle joint. So the surgery will and should vary form pateint to patient.

Re: Pes planus reconstruction

Dr. Biehler on 8/31/00 at 22:31 (026859)

When a person has ligamentus laxity ( you may or may not have this) it allows their bones to move farther in the joints than normal. In children this can give them very flat feet as opposed to being born with their bones making their feet flat. This perdisposes them to bunnions at an early age. If you have forefoot varus, this means with your foot in subtaylor neutral ( the normal alinement of bones while standing) you have an arch but the front of your foot would be slanting at an angle. When your arch colapses the forefoot rests on the ground. When this happens your foot is pronated and that is called pes plannus. In this position the ligaments are at their laxest in the foot which lets the bones spread out and in some theories, this puts the most tension on the plantar fasia as it holds the foot together.With the foot in this position it also has the tarsal tunnel fully streched out and by now has rendered the posterior tibial tendon almost worthless. With orthotics the problem is usually trying to correct everything right away ( a bad idea). I find that an acomadative orthotic with sight arch support and a slight varus post under the forefoot has helped some people alot. In reconstructive surgery they may try to put a plug in the subtaylor joint to keep it from pronating then tighten up the posterior tibial tendon or rearainge other tendons. Either way you are going to need a good orthotic. Dr. Biehler

Re: Pes planus reconstruction

wendyn on 8/31/00 at 22:50 (026861)

Thank you both for such detailed, informative (and fast)replies!

I agree that I need orthotics, so far I've been unable to find any I can wear. I will try another pair depending on what the MRI shows and what the surgeon says. Right now, the problem is that I cannot tolerate a shoe rubbing by my inner ankle (the tarsal tunnel spot). This makes it impossible for me to wear anything other than Birks. I do wear a running shoe with a Birk insert at the gym, but for no more than an hour at a time.

Dr B - I was also told I have a hyper mobile medial column (?) which I think means the joints in my feet move more than they should. I think a lot of the pain I have comes from my post tib tendon - what do you mean when you say 'it renders the post tib tendon pretty much useless'?

All right, so if I were to undergo this type of surgery at my age - what would be the likely outcome? I know you can't predict the future -but what do things look like with AND with out the surgery. Would I be able to hike, bike, go for long walks? Would it reduce the pain? Would it be good for a few years and then just fall apart? If I don't have the surgery, is it likely that things will continue to get worse? How much worse? I'm not looking to run marathons....I just would like some semblance of a normal life.

Re: Pes planus reconstruction

Dr. Biehler on 9/01/00 at 07:20 (026866)

The posterior tendon is what pulls and keeps the arch up. In a severly pes planus foot this has been streched out over the years and all the ligments and muscles in the foot have adapted. There are different surgeries and I think alot of people have been happy with the results. My point is that since your foot has adapted to its position, any orthotic must offer very slight correction to start with and should be comfortable. Even after surgery ( if that is the path you take) you will need an orthotic to help the posterior tendon suport the arch. Dr. Biehler

Re: Pes planus reconstruction

wendyn on 9/01/00 at 07:39 (026870)

Thank you!

What you are saying makes sense. This is probably also why I had such major problems from orthotics #2 - a rigid (very arched) pair that eventually almost crippled me.

Your tendon explanation sounds very similar to what I was told when I was 11 - for about a year my foot flopped around and I walked on the outside of it a lot. I must have done something significant to the tendon then.