Non-surgical treatment includes analgesics, shoewear advice and sometimes adaptations, weight reduction, Achilles tendon stretching and local treatment to irritated joints and tendons. Achilles tendon stretching must be done with the subtalar joint in neutral otherwise the stretching manoevre will simply force the subtalar joint into eversion. We teach the patient’s partner or other available person to do this.
The mainstay of non-surgical treatment is a suitable orthotic device. Flexible flatfeet (up to Truro stage 3) can be treated with a UCBL-type device. This provides as much correction of hindfoot valgus and ankle loading as a calcaneal osteotomy (Havenhill 2005), and produces demonstrable improvement in gait parameters.
Patients with fixed forefoot supination (Truro stages 4-6) need an extension of the orthosis to "raise the ground" to the first ray. However, orthotic treatment is still usually successful.
More extensive bracing has been described for severe deformities.
About 20% of patients present predominantly with arthritic symptoms, most often in the 1st TMT joint. Orthoses, analgesia and injections are useful in this group, but almost half required surgery in Suneja's series.
Both Wapner and Chao (1999) and Jari et al (2002) found that 70% of patients were satisfactorily treated with orthoses and shoe modifications. Only about 10% were operated on, although a number of patients with significant continuing symptoms decided against surgery. Suneja (2006) re-reported Jari's series with longer follow-up and larger numbers. 80% of patients were successfully managed non-surgically, though some had decided to accept significant residual symptoms rather than have reconstructive surgery. Other patients had discarded their orthoses after a year or two without ill-effects.
Non-surgical treatment should be tried in every patient unless there are cogent reasons not to do so. Even imminent skin breakdown over the prominent talar head has been successfully treated with a Scotchcast diabetic boot followed by the use of a total contact inshoe orthosis.
Because the initial treatment is conservative in almost every case, patients whose referral letters imply that they have adult acquired flatfoot are primarily seen, in Blackburn, by the podiatrist rather than the surgical clinic.