Pes valgus (folded foot): causes, symptoms, treatment

What is pes valgus?

In pes valgus, the heel bone (calcaneus) is in an X position: the hindfoot deviates outwards and the foot turns inwards (pronation). The medial longitudinal arch of the foot can be normal, lowered (arch arches) or severely flattened (flat feet). One often speaks collectively of “arched arched foot” or – if the flattened foot is pronounced – “flat foot” (Pes planovalgus).

• Flexible pes valgus: Deformity can be partially corrected by standing on the toes or passively lifting the big toe (windlass mechanism); often with little symptoms.
• Rigid pes valgus: deformity remains unchanged; more often painful, often structural causes (e.g. tarsal coalition, osteoarthritis).

Anatomy & Biomechanics: Why does the foot bend?

The stability of the arch of the foot is ensured by a finely coordinated interaction of bones, ligaments and muscles. Central are the ankle bone (talus), the scaphoid bone (os naviculare) and the heel bone (calcaneus). Key functions are performed by the spring ligament (calcaneonavicular plantar ligament) and the tibialis posterior tendon, which actively support the medial arch.

• Hindfoot axis: Alignment of the heel bone relative to the lower leg; With valgus, the heel moves laterally.
• Subtalar Joint: Controls pronation/supination; Overpronation promotes buckling.
• Tibialis posterior: dynamic stabilizer; Tendon weakness leads to arch drop and valgus.
• Calf muscles/Achilles tendon: Shortening promotes overpronation and incorrect loading.

Typical symptoms

• Stress-dependent pain on the inner edge of the foot/medial ankle (tibialis posterior tendon, spring ligament).
• Later there is often pressure or impingement pain on the outside of the ankle joint/sinus tarsi due to entrapment.
• Feet tire quickly, walking/standing for long periods is uncomfortable; Sports with jumping/running painful.
• Callus formation, shoe pressure medially; uneven shoe wear.
• “Too-many-toes” sign: More toes are visible on the sides from behind (front foot moves outwards).
• Restricted toe stance on one side (single leg heel stance) – indication of tibialis posterior insufficiency.

Causes and risk factors

• Physiological arched foot in children: common up to 6–8 years; mostly flexible and low in symptoms.
• Ligament laxity/hypermobility, connective tissue weakness.
• Tibialis posterior tendinopathy (most common cause of acquired planovalgus in adults).
• Overweight, standing for long periods of time, high walking distances, unsuitable footwear.
• Achilles tendon shortening/calf muscle imbalance.
• Tarsal coalition (bony/connective tissue connection in the hindfoot) – typically rigid deformity in adolescence.
• Post-traumatic or after chronic overload; degenerative changes/arthrosis.
• Neuromuscular diseases (less common).

Special features for children and adults

Children often have flexible pes valgus, which normalizes with growth and muscular maturation. What is important is the symptoms of the symptoms, not just the appearance. Rigidity, one-sided expression or pain require clarification (e.g. exclusion of a tarsal coalition).

In adults, tendon and ligament insufficiency is often the main concern, especially a. the tibialis posterior tendon. If left untreated, the misalignment can progress (acquired flatfoot) and cause secondary damage to the joints. Early conservative therapy can often slow progression.

Examination and diagnostics

• Anamnesis: location of pain, course, strain, footwear, previous illnesses.
• Inspection while standing/gait: heel axis deviation, arch of the foot, “too-many-toes” sign.
• Functional tests: one-legged toe stand (tibialis posterior strength), jack test (windlass), subtalar joint mobility.
• Calf/Achilles tendon length measurement; Assessment of intrinsic muscles.
• Imaging: Weight-bearing x-ray (AP/lateral; Meary angle, talonavicular coverage, calcaneus tilt); If necessary, Salzmann recording for the hindfoot axis.
• Sonography/MRI if posterior tibial tendinopathy or ligament injury is suspected; CT/MRI for tarsal coalition.
• Optional: Pedobarography (pressure measurement) for therapy planning and progress monitoring.

Conservative therapy: the first step

Most patients initially benefit from non-surgical treatment. The goal is to relieve pain, improve function and stop progression. The measures are combined individually and applied consistently over weeks.

Therapy period: Often 8-12 weeks of structured program, for tendinopathies also 3-6 months. Regular progress checks serve for fine control.

Targeted exercises for stability and relief

• Short Foot Exercise: Actively raising the longitudinal arch by tensing the short muscles of the foot (without clawing the toes).
• Theraband inversion with plantar flexion: Strengthens the tibialis posterior; 3-4 sets of 12-15 reps.
• Eccentric heel raises: Slow, controlled lowering phase; Progression on one leg, holding slight supination.
• Calf/soleus stretch: 2-3 times daily, 30-45 seconds each, to counteract Achilles tendon shortening.
• Balance training: one-legged stance, unstable surfaces, step/jump control.

Important: Exercises should be performed with little pain and technically clean. Individual guidance through physiotherapy improves effectiveness.

Insoles, orthoses and footwear

Insoles can support the medial arch, guide the hindfoot axis and relieve strain on tendons. For children, they are primarily used for comfort when the flexible arched foot causes problems.

• Medially posted insoles with heel grip (UCBL principle for pronounced valgus).
• Soft padding in the medial longitudinal arch for pressure-related complaints.
• Stable shoe with fixed heel control element; Test pronation-controlled models during sports.
• Short-term stabilizing ankle joint orthoses in acute phases of irritation.

Injections and regenerative procedures: when does it make sense?

If there is inflammatory irritation in the tendon bearing, ultrasound-assisted infiltration can be considered in selected cases. Cortisone in the direct tendon tissue is avoided due to an increased risk of rupture of the tibialis posterior tendon. Biological procedures (e.g. PRP) are discussed to help with tendinopathies; the evidence is heterogeneous and benefit is not certain. Such options should be examined individually, cautiously and always in addition to functional therapy.

Surgical options (if conservative therapy fails)

Surgery is considered if, despite consistent conservative measures, persistent pain persists, the misalignment progresses or structural causes require correction. The specific procedure depends on age, flexibility of the deformity, accompanying findings and activity level.

• Hindfoot osteotomies: Medializing calcaneal osteotomy for axis correction; If necessary, lateral column extension (Evans) for forefoot/midfoot abduction.
• Soft tissue procedures: debridement/tendon augmentation of the tibialis posterior tendon, spring ligament/spring ligament reconstruction; If necessary, flexor digitorum longus transfer.
• Forefoot/midfoot corrections: Cotton osteotomy (medial wedging) for persistent forefoot varus.
• Gastrocnemius recession/Achilles tendon lengthening in functional equinus contracture.
• Arthroeresis (subtalar spacers): in selected cases, especially a. in adolescents – evidence and long-term results are controversially discussed.
• Arthrodesis: Subtalar or triple arthrodesis for rigid deformity/arthrosis (stage III/IV).

Follow-up treatment: Depending on the procedure, partial to full relief for 4-6 weeks, then gradual increase in load, physiotherapy, later adjustment of the insoles. The individual risks and the expected course are discussed in detail preoperatively.

Course and prognosis

Many patients with flexible pes valgus achieve good symptom control with insoles, targeted physiotherapy and training adjustments. In the case of acquired flatfoot, early therapy can often slow down the progression. Without treatment, there is a risk of overload damage to the tendons/ligaments, lateral impingement and – in the long term – joint wear.

Prevention and everyday tips

• replace shoes in a timely manner; Pay attention to stable heel support and a torsion-stable sole.
• Training control: Moderately increase the scope and intensity, plan recovery phases.
• Regular foot and calf strengthening program, especially for pronation-heavy sports.
• maintain weight within a healthy range; every reduction relieves pressure on the foot and tendons.
• Have early warning signs (medial ankle pain, one-legged toe stand hardly possible) clarified.

When should I see a doctor?

• Persistent pain in the inner or outer ankle despite relief and insoles.
• Increasing misalignment or asymmetry of the feet.
• Inability to stand on one leg on toes, especially when compared from side to side.
• Recurrent twisting events, feeling of instability.
• Children/adolescents with painfully rigid misalignment or significant one-sidedness.

In our practice in Hamburg (Dorotheenstrasse 48, 22301 Hamburg) we clarify complaints in a targeted manner and plan an individual, preferably conservative, treatment with you.