Occasionally, symptoms can be more severe and surgery to repair or replace the damaged tendon with or without a realignment procedure of the heel bone becomes necessary. This has the advantage to preserve movement in the hindfoot joints, but if these are damaged due to a longstanding loss of shape in the foot, a stiffening operation to restore and maintain foot shape & function may be the only option (triple arthrodesis).

A rare cause of a painful flatfoot particularly in the adolescent is the failure of bones in the back of the foot to separate during growth. Surgery to separate or stabilize them is often recommended.