Warning

Flatfeet is a common condition, in which the arches on the inside of the feet flatten when pressure is put on them. When people with flatfeet stand up, the feet point outward, and the entire soles of the feet fall and touch the floor.

Flatfeet can occur when the arches don't develop during childhood. It can also develop later in life after an injury or from the simple wear-and-tear stresses of age.

Flatfeet is usually painless. If no pain is present, no treatment is necessary. However, if flatfeet is causing pain and limiting what you want to do, then an evaluation may be warranted.

Posterior tibial tendon dysfunction (PTTD)

 This is a condition caused by changes in the tendon, impairing its ability to support the arch. This should be referred to podiatry early. If left for too long, it can result in flattening of the foot.  PTTD is often called adult acquired flatfoot because it is the most common type of flatfoot developed during adulthood.

Flat foot

Symptoms may include

  • pain,
  • swelling,
  • a flattening of the arch and an
  • inward rolling of the ankle.

As the condition progresses, the symptoms will change. For example, when PTTD initially develops, there is pain on the inside of the foot and ankle (along the course of the tendon). In addition, the area may be red, warm and swollen.

Later, as the arch begins to flatten, there may still be pain on the inside of the foot and ankle. But at this point, the foot and toes begin to turn outward, and the ankle rolls inward.

As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. The tendon has deteriorated considerably, and arthritis often develops in the foot. In more severe cases, arthritis may also develop in the ankle.

 

Who to refer, who not to refer, how to refer

Who to Refer

  • Those who have failed Primary care management

Urgent Referral Criteria

  • Nil

Who Not to Refer

  • Those who have not tried Primary care management

Additional Info 

  • 99% of these will go to Podiatry – refer to them unless they have had input from them already
  • Unlikely to operate if BMI >40

Imaging

  • Nil required

How to refer

We accept referrals through SCI gateway for those who are based in Scotland.

We also accept e referrals through the below email address using the attached form for those who are based just on the other side of the border. 

E- Referral Email address - bor.orthoreferrals@borders.scot.nhs.uk

Referral form - E-Referral to Orthopaedics (Non Sci-Gateway)      

Primary care management

  • Physio rehab- strengthening – focus on eccentric tibialis posterior and glutes over extended period (1yr)
  • Off the shelf orthotics to support mid arch and invert hindfoot for 2/12 without success
  • Podiatry Input
  • Regular maximum multimodal analgesia
  • Education
  • BMI >35 engage in wellbeing support

Resources and links

Primary Care Foot Pathway  - developed by First Contact Practitioners / Podiatry (To be confirmed, will update when available)

Editorial Information

Last reviewed: 31/07/2025

Next review date: 31/07/2027

Author(s): Mr Roshan Raghavan.

Author email(s): Roshan.Raghavan@nhs.scot.