Articulated arched arches

What is arch arches? Anatomy and terms

The foot normally forms a stable, resilient longitudinal arch on the inside. It is supported by bones (including talus, scaphoid, heel bone), ligaments (spring ligament, plantar aponeurosis) and muscles/tendons (especially tibialis posterior muscle). In arched arched feet, the heel tilts outwards/valgically, causing the rear foot to bend inwards. At the same time, the medial vault descends.

• Bent foot: valgic heel position (rear foot tilts outwards).
• Fallen arch: Flattening of the inner longitudinal arch.
• Pes valgoplanus: combined deformity; colloquially often called “arch arches” or “(acquired) flat feet”.

It is important to differentiate between flexible (misalignment can be corrected manually or by standing on tiptoe) and rigid (fixed). Flexible shapes, v. a. in children, are usually functional and can be treated conservatively. Rigidity is more likely to indicate a structural cause (e.g. tarsal coalition or advanced osteoarthritis).

Causes and risk factors

A arched arched foot arises from an interaction between connective tissue, muscles and stress. Common triggers vary depending on age and comorbidities.

• Children/adolescents: often flexible foot shape due to still maturing connective tissue and muscles.
• Connective tissue laxity/family history: inherited ligament laxity favors the subsidence of the arch.
• Excess weight and standing activities: additional mechanical stress on the arch of the foot.
• Overpronation in athletes: repetitive stress on the tibialis posterior tendon.
• Posterior tibialis tendon insufficiency (PTTD): the leading cause of acquired arched arches in adults.
• Inflammatory rheumatic diseases: ligament/tendon weakness and joint damage.
• Trauma or microtrauma: e.g. B. Distortions, insufficiency of the spring ligament.
• Tarsal coalition (bony/fibrous connection between tarsal bones): v. a. in young people, often painful and rigid.
• Neurological causes: rare, then often further misalignments.
• Pregnancy/hormonal changes: temporary ligament laxity.

Typical complaints

• Stress-related pain on the inside of the foot/ankle (along the tibialis posterior tendon).
• Tiredness pain after standing/walking for long periods of time, walks become shorter.
• Swelling or tenderness behind/under the inner ankle.
• Shoe soles wear on one side; Inward tilting noticeable.
• Advanced: Pain on the outside of the foot (sinus tarsi/peroneal tendons) as the load shifts.
• Common companions: calf tension, Achilles tendon shortening, heel pain (plantar fascia).
• Limited sports tolerance, unsteady feeling in the ankle.

Stages and forms

Adult patients with PTTD are often classified according to Johnson & Strom/Myerson. This classification helps with therapy planning:

The flexible form dominates for children and young people. A rigid misalignment or significant pain suggests a specific cause (e.g. tarsal coalition) and should be clarified by an orthopedist.

Diagnostics in practice

The diagnosis is easy to make clinically. A careful examination will show how severe the misalignment is and whether it is flexible or rigid.

• Inspection while standing under load: arch height, heel axis, “too-many-toes” sign from behind.
• Heel stand/one-legged tiptoe stand: does the arch lift? Does the heel tip back into varus? (Function of the tibialis posterior tendon)
• Gait analysis: rolling pattern, step width, rotation errors.
• Muscle function/extensibility: calf muscles (Silfverskiöld test), inner foot muscles.
• Palpation: tenderness along the tibialis posterior tendon, spring ligament, peroneal tendons.
• Imaging: X-ray under weight (AP, lateral; Saltzman view for hindfoot axis if necessary).
• Sonography: tendon structure/inflammation; MRI for unclear tendon damage.
• If tarsal coalition/rigid deformity is suspected: CT is useful.
• Laboratory if rheumatic genesis is suspected.

Conservative treatment – ​​first

Our goal is to relieve pain, improve function and stop possible progression - with everyday measures. Most patients benefit significantly from a structured conservative program.

• Activity adjustment for a limited time: allow irritating pain to calm down; Reduce shock loads.
• Targeted physiotherapy: strengthening the tibialis posterior muscle and the internal foot muscles; Stretching the calf muscles.
• Insoles: supportive, medially positioned insoles, possibly UCBL shells or functional orthoses (e.g. Richie Brace) for severe deformities.
• Shoe selection: stable heel support (heel cap), torsion-stable sole, light medial support; no worn-out footwear.
• Taping/orthotics in phases of overload.
• Weight management and compensatory training (e.g. cycling, swimming).
• Pain and inflammation management: local cooling, short-term NSAIDs as needed and tolerated; Protection without complete immobilization.
• In acute PTTD: temporary immobilization in a walker/orthosis, then gradual increase in load.

Cortisone injections directly to the tibialis posterior tendon are usually avoided as they may be associated with an increased risk of tendon rupture. Biological injections (e.g. PRP) are not scientifically proven for this indication and are - if at all - only considered after careful information and an individual benefit-risk assessment.

Exercises for home

Exercises are the core building block. Train 4-5 days per week, adapted to pain. Quality comes before quantity.

Increase slowly. Stop if you experience sharp pain and seek medical advice if symptoms worsen.

Insoles, shoes and everyday tips

Insoles and suitable footwear support the arch and relieve pressure on irritated structures. The care is individual – what works for one person is too hard or too soft for another.

• Insoles with medial support/posting, if necessary with heel guide (shell).
• Stable shoe with a firm heel cap, sufficient torsional stability and a slight drop.
• For running activities: test models with moderate pronation support; Running analysis makes sense.
• Change worn shoes early - “worn out” shoes increase the misalignment.
• In everyday life, short periods of barefoot walking on soft, varied surfaces are okay; In case of acute irritation, it is better to walk stably.
• Work: If necessary, changing insoles and shoes during the day (office/workplace).

Arched arches in children and adolescents

The flexible arched arch foot in childhood is often a normal developmental variant. There is usually no pain and the arch forms as muscle strength and bone maturity increases.

• Observe instead of overtreating: Insoles are often not necessary if the foot is symptom-free and flexible.
• Complaints, limping, restricted exercise or very rapid fatigue suggest an orthopedic examination.
• Warning signs: rigid (uncorrectable) misalignment, significant asymmetry, persistent pain – e.g. B. Suspected tarsal coalition.
• Promotion: playful exercises, a variety of incentives to move, good shoes; short barefoot phases on safe ground.

Acquired arch arches in adulthood (PTTD)

The posterior tibialis tendon stabilizes the longitudinal arch and controls pronation. If there is overload, degeneration or a tear, insufficiency develops - the arch sinks and the rear foot buckles.

• Risk factors: long-term overpronation, obesity, diabetes, smoking, rheumatic diseases.
• Acute phase: pain/swelling behind the inner ankle; Relief and anti-inflammatory measures are key.
• Interval therapy: after the acute phase has subsided, targeted muscle training and supportive orthoses to slow progression.
• Regular follow-up: early adjustment of therapy to prevent progression.

When does an operation make sense?

An operation is only considered if conservative measures have been consistently exhausted over several months and there are still significant restrictions or the deformity progresses. The choice of procedure depends on the stage, flexibility and accompanying findings.

• Early stages/tendon pathology: Debridement/suture of the tibialis posterior tendon, often combined with tendon transfer (e.g. flexor digitorum longus) to support function.
• Bone corrections: medializing heel bone osteotomy (calcaneus), lateral lengthening of the outer foot (Evans), corrections to the scaphoid/sphenoid bone.
• Ligament reconstructions: Spring ligament reconstruction in insufficiency.
• Calf muscle/Achilles tendon lengthening during shortening with limited dorsiflexion.
• Advanced rigid stages: Joint stiffening (subtalar, talonavicular, calcaneocuboid or triple arthrodesis) for low-pain stability.

Surgical decisions are made individually. Rehabilitation times, temporary restrictions, thrombosis prophylaxis and risks (infection, impaired wound healing, dissatisfaction despite correct technique) are discussed in detail in advance. Our practice focuses on conservative therapy; For surgical measures, we cooperate with experienced foot surgery centers.

Course, prognosis and prevention

Symptoms can often be easily controlled with early, consistent conservative treatment. Regular exercises, adjusted loads and suitable footwear are crucial. Complete “regression” of structural changes is rare, but function can be significantly improved.

• React early: the earlier the irritation is treated, the better the prognosis.
• Weight management reduces the load on the arch.
• Maintain exercise routine – especially posterior tibialis strengthening and calf mobility.
• Check shoes/insoles regularly and replace them if necessary.
• Optimize comorbidities (e.g. diabetes, rheumatism).

Warning signs – when should you seek medical advice?

• Acute, severe pain or sudden swelling in the inner ankle (suspected tendon rupture).
• Pain at rest, pain at night, significant warmth/redness.
• Newly occurring rigid misalignment or increasing deformity.
• Sensory disturbances, weakness, repeated twisting.
• Non-healing skin areas/ulcers (especially in diabetes).
• Fever or general symptoms in combination with joint pain.

What does the evidence say?

Systematic reviews show clinically relevant symptom improvement in flexible arched arches and PTTD for combinations of an exercise program and supportive insoles, especially in early stages. Orthotics can slow progression if worn consistently. Cortisone injections to the tibialis posterior tendon are assessed cautiously (risk of rupture). For PRP or other regenerative injections, the evidence is mixed; A general recommendation cannot currently be derived.

Your treatment in Hamburg-Winterhude

We take time for anamnesis, functional diagnostics, gait and your goals in everyday life or sport. On this basis, we create a structured, conservative therapy plan and closely monitor your progress - from the insole and shoe concept to the individual exercise program.

Practice address: Dorotheenstraße 48, 22301 Hamburg. You can easily obtain appointments online via Doctolib or by email. We look forward to hearing from you.