Pes planovalgus, commonly referred to as flatfoot, is a deformity characterized by the collapse of the foot’s arch and outward angulation (valgus) of the heel. This condition can cause significant pain, gait abnormalities, and difficulty with footwear. While conservative management such as orthotics, stretching, and physical therapy is often effective in mild cases, surgical reconstruction becomes necessary for patients with persistent symptoms or progressive deformity.
How Common It Is and Who Gets It? (Epidemiology)
Flatfoot deformities are common across all age groups. In adolescents, idiopathic flexible pes planovalgus (IFPP) occurs without a known cause and is usually due to ligamentous laxity or biomechanical imbalance. In adults, acquired flatfoot is often caused by posterior tibial tendon dysfunction (PTTD), trauma, or systemic disorders such as rheumatoid arthritis or diabetes. Adult acquired flatfoot affects up to 10% of women over age 40, often progressing if left untreated.
Why It Happens – Causes (Etiology and Pathophysiology)
Flatfoot develops when the structures that support the medial arch—especially the posterior tibial tendon, spring ligament, and plantar fascia—become weak or fail. In children and adolescents, this may result from flexible ligaments, while in adults, the posterior tibial tendon often degenerates or tears. Over time, the talus shifts downward and inward, the arch collapses, and the heel rotates outward. Tightness in the Achilles or gastrocnemius muscle can further worsen the deformity.
How the Body Part Normally Works? (Relevant Anatomy)
The foot’s arch is supported by a network of bones, ligaments, and tendons, including the calcaneus (heel bone), talus, navicular, and first metatarsal. The posterior tibial tendon acts as a dynamic stabilizer, supporting the arch during walking. The spring ligament provides static support to the medial side of the foot. When these structures fail, the arch collapses, the forefoot abducts, and the heel drifts into valgus alignment.
What You Might Feel – Symptoms (Clinical Presentation)
Common symptoms of pes planovalgus include:
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Pain and fatigue along the inside of the foot and ankle.
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Swelling around the posterior tibial tendon.
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Difficulty standing on tiptoes or prolonged walking.
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A visibly flattened arch when standing.
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Outward tilt of the heel and forefoot abduction.
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Calluses or uneven wear on the inside of the foot.
In severe cases, pain may develop on the outer side of the foot due to impingement of the calcaneus and fibula.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis begins with a physical exam, gait analysis, and imaging studies. The “too many toes” sign—where more toes are visible from behind the patient—indicates valgus deformity. X-rays of the foot measure angles such as the talonavicular coverage and calcaneal inclination. MRI may be used to evaluate tendon degeneration or ligament tears. In some cases, the Beighton score helps assess generalized ligament laxity.
Classification
Pes planovalgus is classified as either flexible or rigid. Flexible flatfoot shows an arch when the patient rises on tiptoe, while rigid flatfoot does not. Acquired adult flatfoot is staged from I to IV based on the extent of posterior tibial tendon dysfunction:
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Stage I: Tendon inflammation, no deformity.
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Stage II: Flexible deformity with tendon attenuation.
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Stage III: Rigid deformity with subtalar arthritis.
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Stage IV: Deformity extending to the ankle joint.
Other Problems That Can Feel Similar (Differential Diagnosis)
Conditions that can mimic pes planovalgus include tarsal coalition, midfoot arthritis, plantar fasciitis, and peroneal tendon injury. Clinical examination and imaging help differentiate these from flatfoot.
Treatment Options
Non-Surgical Care
Conservative treatment includes orthotics, custom insoles, and physical therapy to strengthen the posterior tibial tendon. Supportive footwear and anti-inflammatory medications help control pain. Calf stretches and night splints may relieve Achilles or gastrocnemius tightness.
Surgical Care
When conservative measures fail, surgical reconstruction is required to restore normal alignment and function. The procedure is individualized based on the severity of deformity and involves both bony realignment (osteotomies) and soft tissue repair.
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Lateral Column Calcaneal Lengthening (LCL) Osteotomy (CPT 28304):
Lengthens the outer side of the heel bone to correct forefoot abduction and improve coverage of the talonavicular joint. A bone graft, typically 8–11 mm, is inserted into the osteotomy site. -
Medializing Calcaneal Osteotomy (CPT 28300):
Shifts the posterior calcaneus inward to correct valgus alignment and restore balance to the hindfoot. -
Flexor Digitorum Longus (FDL) Tendon Transfer (CPT 27691):
The FDL tendon is transferred to support or replace the weakened posterior tibial tendon, strengthening the medial arch. -
Spring Ligament Plication (CPT 28200):
Tightens the spring ligament to improve arch support and restore stability. -
Medial Cuneiform (Cotton) Osteotomy (CPT 28306):
Places a bone graft in the medial cuneiform to correct forefoot supination and improve alignment of the first ray. -
Accessory Navicular Excision (CPT 28238):
Removes an accessory bone on the inside of the foot that may contribute to flatfoot deformity, followed by reattachment of the posterior tibial tendon. -
Gastrocnemius Recession or Achilles Lengthening (CPT 27687, 27606):
Lengthens tight calf muscles to improve ankle flexibility and reduce strain on the arch.
Recovery and What to Expect After Treatment
Following surgery, patients typically remain non-weight-bearing for six weeks using crutches or a knee scooter. Partial weight-bearing with a walking boot is allowed for an additional four weeks. Physical therapy begins after cast removal to strengthen the foot and restore mobility. Full recovery, including a return to normal footwear and activities, usually takes 3–6 months.
Possible Risks or Side Effects (Complications)
Complications may include nonunion or delayed union of bone grafts, especially with allografts. Other risks include infection, nerve irritation, persistent pain, and recurrence of the deformity. Hardware used for fixation may require later removal.
Long-Term Outlook (Prognosis)
Surgical reconstruction for pes planovalgus provides durable correction and significant pain relief. Studies report improvements in American Orthopaedic Foot and Ankle Society (AOFAS) scores from an average of 56.7 preoperatively to 95.3 postoperatively. Proper surgical technique and postoperative rehabilitation result in excellent long-term alignment and function.
Out-of-Pocket Costs for Treatment
Medicare
CPT Code 28304 – Lateral Column Calcaneal Lengthening: $191.57
CPT Code 28300 – Medializing Calcaneal Osteotomy: $153.01
CPT Code 27691 – Flexor Digitorum Longus (FDL) Tendon Transfer: $175.25
CPT Code 28200 – Spring Ligament Plication: $113.23
CPT Code 28306 – Medial Cuneiform (Cotton) Osteotomy: $139.80
CPT Code 28238 – Accessory Navicular Excision: $151.78
CPT Code 27687 – Gastrocnemius Recession: $106.77
CPT Code 27606 – Achilles Tendon Lengthening: $63.37
Medicare Part B typically covers 80% of the approved cost for these procedures once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield generally cover that remaining 20%, minimizing or eliminating out-of-pocket expenses for Medicare-approved procedures. These plans are designed to coordinate with Medicare to fill the coverage gap and reduce total patient costs.
If you have Secondary Insurance, such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it serves as a secondary payer. These plans often cover any remaining coinsurance or small deductibles, which typically range between $100 and $300, depending on your plan and provider network.
Workers’ Compensation
If your flatfoot deformity or resulting reconstructive surgery is required due to a work-related injury or repetitive strain, Workers’ Compensation will cover all related medical expenses, including surgery, rehabilitation, and postoperative care. You will have no out-of-pocket expenses, as the employer’s insurance carrier directly pays for all approved services.
No-Fault Insurance
If your flatfoot deformity or related injury was caused or aggravated by an automobile accident, No-Fault Insurance will typically cover the full cost of treatment, including all reconstructive and tendon procedures. The only potential out-of-pocket cost may be a small deductible or co-payment, depending on your policy.
Example
Anthony Rivera had adult acquired flatfoot deformity with tendon insufficiency and arch collapse. His reconstruction involved calcaneal osteotomy (CPT 28300), FDL tendon transfer (CPT 27691), and gastrocnemius recession (CPT 27687). His estimated Medicare out-of-pocket costs totaled approximately $175.25 for the tendon transfer and smaller amounts for the other components. Because Anthony carried supplemental insurance through Blue Cross Blue Shield, his remaining balances were fully covered, leaving him with no out-of-pocket expenses for the entire reconstruction.
Frequently Asked Questions (FAQ)
Q. What is pes planovalgus?
A. It is a condition where the arch of the foot collapses, causing the heel to tilt outward and the foot to flatten.
Q. When is surgery needed?
A. Surgery is required for persistent pain, progressive deformity, or failure of conservative treatments such as orthotics or therapy.
Q. How long is the recovery?
A. Recovery typically takes 3–6 months, with non-weight-bearing for the first six weeks followed by gradual return to walking.
Q. Can multiple procedures be performed together?
A. Yes. Flatfoot reconstruction usually combines bony and soft tissue procedures to correct all components of the deformity.
Q. Will I walk normally after surgery?
A. Most patients regain full walking ability with improved foot mechanics and pain-free mobility.
Summary and Takeaway
Pes planovalgus reconstruction is a transformative procedure that restores alignment, stability, and pain-free function in patients with severe flatfoot deformity. By combining osteotomies and soft tissue procedures, surgeons can address both structural and functional abnormalities, significantly improving quality of life.
Clinical Insight & Recent Findings
A recent study compared sensorimotor and supportive insoles in adults with flexible flatfoot and found that sensorimotor insoles, combined with foot exercises, improved arch stability and reduced foot contact area, indicating a more active muscular correction.
In contrast, supportive insoles relieved pain more quickly but tended to increase the foot’s contact area and potentially weaken the arch-supporting muscles over time.
Overall, the study concluded that long-term foot muscle training and selective use of sensorimotor insoles can enhance both function and comfort without the drawbacks of continuous passive support. (“Study comparing supportive vs. sensorimotor insoles for flexible flatfoot – see PubMed.“)
Who Performs This Treatment? (Specialists and Team Involved)
Pes planovalgus reconstruction is performed by orthopedic foot and ankle surgeons or podiatric surgeons specializing in reconstructive foot surgery. The multidisciplinary team includes anesthesiologists, nurses, and physical therapists for postoperative care.
When to See a Specialist?
Consult a specialist if you experience chronic arch pain, difficulty walking, or worsening foot deformity despite conservative management.
When to Go to the Emergency Room?
Seek immediate care if you develop severe pain, swelling, redness, drainage, or fever after surgery, which may indicate infection or hardware-related issues.
What Recovery Really Looks Like?
The recovery process requires strict adherence to non-weight-bearing and gradual rehabilitation. Physical therapy focuses on rebuilding strength and flexibility. Most patients return to daily activities within six months.
What Happens If You Ignore It?
Untreated pes planovalgus can lead to progressive deformity, chronic pain, and arthritis in the midfoot and ankle, potentially requiring more complex reconstructive surgery later.
How to Prevent It?
Wear supportive shoes, avoid prolonged standing in unsupportive footwear, maintain a healthy body weight, and perform regular strengthening exercises for the foot and calf.
Nutrition and Bone or Joint Health
A diet rich in calcium, vitamin D, and protein promotes bone healing after surgery. Avoid smoking, which impairs circulation and delays recovery.
Activity and Lifestyle Modifications
After recovery, continue using supportive footwear and participate in low-impact activities like cycling, swimming, or yoga to maintain foot strength and flexibility. Regular check-ups ensure lasting results and prevent recurrence.
Dr. Mo Athar
