Flat Foot Repair

What is Flat Foot or Hyperpronation?

Pronation is a normal motion of the foot. Specifically, it is the complex motion between the ankle bone, which turns inward, and the rest of the foot which turns out. This is a very important function of the foot to aid walking, especially on uneven ground. Pronation is the body’s shock absorber, it helps the body adjust to the impact of walking or running.

Hyperpronation is a very common deformity when there is excessive or too much pronation occurring in the foot. The arch of the foot adopts a flattened appearance and allows excessive foot motion. This excessive motion occurs in the ankle and the heel as well as the rest of the foot every step taken.

Hyperpronation also causes knees to turn inwards and can be responsible for knee, hip and low back pain. Patients can present with pains in multiple joints in their feet and legs.

The non-surgical correction of flat foot or hyperpronation can be achieved with orthoses (Foot supports) and exercise programmes. Have a look at our Posture analysis page.

Flat foot or Hyperpronation results in the abnormal closure of the sinus tarsi. This is a area between the bones of the heel. A simple surgery correction of hyperpronation is to insert a spacer into the sinus tarsi to prevent hyperpronation. This implant is called an Sinus Tarsi arthrodesis.

In severe cases of flat foot, years of hyperpronation can cause tendon degeneration and degeneration of joints. These feet are not suitable for Sinus Tarsi arthrodesis. In these cases different surgical procedures are performed to correct the specific area of degeneration in each person. These corrective foot surgery procedures could include

Flat Foot Synonyms and related keywords: pes planus, acquired adult flatfoot, posterior tibial tendon dysfunction, PTT dysfunction, posterior tibial tendon insufficiency, PTT insufficiency, Chopart joint, too-many-toes sign, Evan calcaneal osteotomy, Calcaneal displacement osteotomy.

Hypocure Sinus Tarsi Arthroesis

Dr Michael Graham, US Doctor of Podiatric Medicine, developed the Hypocure Sinus Tarsi Arthroesis. Your Post operative care at Fitter Feet For life, follows his guidelines below.

Post operative Care following Sinus Tarsi Arthroesis
This is a generalized post-op course and my recommendations. Every physician will have a different post-operative regimen. Each patient and each foot will vary in the post-op recovery following this procedure. One foot will heal faster and with less pain than the other. Some patients return to my office five to seven days post-op, wearing regular shoes with little discomfort. While other patients present to the office using crutches for 3 to 4 weeks after the surgery. Every patient has different pain tolerances and sometimes the amount of post-op discomfort is increased with the amount of correction achieved with the implant. The size of the implant inserted does not necessarily mean increased post-op pain.
- Michael E. Graham, DPM, FACFAS

First 3 to 5 Days
The surgical site should be numb for 6 to 8 hours after the surgery. We recommend taking the pain medication before you have pain. If you feel a tingling sensation to the surgical site, take the pain medication. Take the pain medication before the numbness wears off. If you wait until you have pain it will take longer for the pain medication to work. Patients who take the pain medication while the foot is still numb have a better transition from "numb" to "not-numb". The leading cause of post-op pain is inflammation. We recommend an anti-inflammatory medication on a regular basis for up to 6 to 8 weeks. Everyone responds differently to the anti-inflammatory medication(s). If you take the anti-inflammatory medication and there is no relief, then most likely the anti-inflammatory is not "working" for you and you should try a different one. Also, we have found that a 5 day course of low dose steroid medication may also aid in decreasing post-op discomfort.

Stay off the foot as much as possible. Initially, your foot will feel great, it is numb. The more walking you do, the more inflammation and trauma you are causing to the surgical site and the more post-op pain you will experience. Use crutches or a walker to stay off your foot.

Elevate whenever possible. When your foot is on the floor, gravity will pull the normal fluids in your leg down to the foot and ankle. The fluid will cause swelling which expands the incision leading to increase in pain and possible pulling on the incision. This edema will delay your healing and recovery. By elevating you will decrease the swelling, thereby decreasing your recovery. Also, it is very important to be careful what you eat and drink during your recovery. It has been my experience that many patients, since that are just sitting or laying around for 10 to 14 days, will consume salty foods become thirsty and drink large amounts of soda (high in sodium content) or other liquids. Salt and fluids are NOT a good combination. Salt is a magnet for fluid and our body will retain fluid and therefore leading to significant edema. So during the post-op course we recommend a very low salt diet and decrease your fluid intake. This will help to decrease your post-op swelling. Sometimes I find it necessary to prescribe a low dose water pill for up to a few weeks until the edema is resolved.

Ice is a very effective post-op tool. The majority of post-op pain is due to the inflammation. By applying ice to the outer ankle 15 to 20 minutes per hour this will help to reduce the inflammation and pain. Never apply the ice directly on the skin. A bag of frozen peas or corn, moulds to the ankle better than a bag ice cubes. Ice should be applied to the surgical site up to 6 to 8 weeks.

I recommend removing the dressings applied to the foot/ankle 3 to 4 days after surgery, if this was the only procedure performed. The second most common cause of post-op pain is the dressing/bandage. Since this procedure is performed through a very small incision only an adhesive bandage is required to cover the incision. Also, when the dressing is applied the patient usually has to wear a post-op shoe when ambulating. The post-op shoe is the third most common cause of post-op pain. So by removing the dressing a more comfortable shoe can be worn. Once the dressings are removed, the patient is allowed to shower. The adhesive bandage must be applied during the shower and "must" be changed after the shower. The foot should not be soaked until the incision is well healed.

Usually, the morning/day after the surgery is when the patient is at the highest level of pain. The pain will decrease everyday thereafter.

7 to 10 Days Post-op
Within 10 days you should have returned to the surgery for a check of the surgical site and to follow up with any other questions or concerns. Usually by the 10th day there is a significant improvement in the ability to walk. Be careful with the way you walk. The area around the incision is still tender and inflamed making it difficult to walk "normal". Some patients will walk in-toed or may walk on the outside of the foot. Walking on the outer part of the foot may cause the implant to get displaced or dislodged. As the inflammation decreases you will be able to walk on the bottom of your foot.

2 to 3 Weeks Post-op
This is the time period your Podiatric Surgeon will take post-op weight-bearing x-rays. Weight-bearing x-rays are essential to verify the correction achieved from the surgery. Before this period the patient may not be able to stand with their foot flat on the floor. The post-op x-rays should not be taken until the foot can be flat on the film or otherwise the x-rays will not give an accurate foot position or placement of the implant in the sinus tarsi. Also, during this period sutures are safe to remove. Sometimes it may take up to 4 weeks to remove sutures. This area has a lot of pulling and stretching and it is better to leave the sutures in place longer than to remove them too soon and have the incision gap open and will then takes several weeks to heal.

4 to 6 Weeks Post-op
During this period you will be able to increase you activity level. Scar tissue will surround the implant to help hold it in place. You should be able to perform most activities during this period. However, you will still have ankle soreness and will most likely have soreness walking up and down stairs. You may develop a "Sprained Ankle Syndrome". This is a potential post-op symptom of pain to the front of the outer ankle bone. The pain comes from the stretching out the anterior tibial-fibular ligament. This develops because the sinus tarsi was closing abnormally which leads to a contracting of the ligament, now that the implant is in place there is a stretch placed on the ligaments. Patients with this condition will experience pain when they first get out of bed in the am or after they have been sitting for a while and get up to walk and usually within a few minutes the pain subsides. A cycle develops where the ligament is stretched during walking/standing and when one sits down the stretch is taken off the ligament and it will then contract, so that when one starts to walk/stand again there is pain due to the stretching out of the ligament. If there is significant pain, care must be taken to treat this syndrome. This can be the most difficult part of the recovery. Not all patients experience this syndrome but I have had patients whose ligament would not stretch-out and therefore would not tolerate the correction, resulting in either downsizing or removal of the implant. "Sprained Ankle Syndrome" needs to be aggressively treated. If there is significant pain to this area post-op steroid injections should be given, 5 day course of low dose oral steroid medication, as well as NSAID's should be prescribed, as well as ice, local massage. Sometimes, physical therapy is necessary to aid in the recovery of this ligament. Also, during this time it is important for the patient to limit themselves from prolonged standing or walking. There is no way to predict who will develop this condition and it may not develop in both ankles. Ligaments and tendons take the longest of any structure of our body to heal due to the limited blood supply. Therefore, it is possible that it may take 4 to 6 months for the ligament to finally "stretch-out". If there is no improvement after 6 to 8 months of conservative therapy it is most likely that the patient's ligament will not get "stretched out"and the implant should be downsized or removed.

Another symptom that may develop up to this point is plantar fasciitis/heel/arch pain. Since the mechanics of the feet have been restored to the foot, a new strain will be placed on the soft tissues on the bottom of the foot. If this develops usually within a week or two the soreness should subside. Rolling the foot on a frozen water bottle, etc, will help with this.

Also, there will most likely develop soreness to the top of the foot and the front of the ankle. This, again, is due to the correction achieved with the implant and there is a return of the normal function of the tendons and ligaments to these areas. Ice will be very beneficial, the soreness will continue to resolve without any problem.

Post-op Pain Cycle
There are various peaks and valleys of pain after surgery. The first day after surgery is usually when pain is at the highest. Since the patient has stayed off the foot the pain will decrease. Several days after the patient begins to walk on the foot and now there is an increase in post-op pain due to the increased demands to the surgical site. This is why it is important to ice several weeks/months after surgery. After sometime, the soft tissues get used to the new strain and the pain will slowly decrease until it is almost resolved. Since there is now a decrease in the pain, the patient will increase activities placing more strain on the soft tissues and along with that there will be a return of pain. Again, ice and anti-inflammatory medications are helpful during this period. The soft tissues will adjust to this additional strain and eventually the pain will again subside. After several months it is still possible to have a recurrence of soreness, say if the patient started running for the first time since surgery. The soft tissue still are not used to this amount of strain and will adjust accordingly and the cycle should then be over.

2 - 3 Months
The soft tissues will really start adjusting and there will be a significant reduction in the post-op soreness. There should be minimal limitations at this point. Pain/soreness will be present when you get out of bed in the morning. If you do experience this discomfort you should be still taking anti-inflammatory medication and should be icing the area 15 to 20 minutes before you go to bed.

4 - 6 Months
The tendons and ligaments should be used to the forces acting on them. The soft tissues should be stretched out and the majority of post-op discomfort should be resolved. Some patients will still be experiencing the soft tissue adjustments. Don't get disappointed if there is still discomfort. Remember the implant has repositioned your foot and it just may take some time for your foot to adjust.

6 - 8 Months
There should be no limitations and minimal discomfort. If significant discomfort is still present, most likely there is an inability for the soft tissues to adjust to the new position. If this occurs, discussion on either downsizing of the implant or implant removal should be discussed.

1 Year
After one year should be no residual complaints. An occasional twinge may be normal.

Post-operative care in summary

Day of Surgery

Day after Surgery

3-4 Days after Surgery

7-10 Days after Surgery

2-3 Weeks after Surgery

4-6 Weeks after Surgery

2-3 Months after Surgery

4-6 Months after Surgery

6-8 Months -1 Year after Surgery

Potential Complications

Download our factsheet on the potential compliations of Sinus Tarsi Arthroesis (pdf document).