Adult acquired flatfoot deformity
(AAFD), embraces a wide spectrum of deformities. AAFD is a complex pathology consisting both of
posterior tibial tendon insufficiency and failure of the capsular and ligamentous structures of the foot. Each patient presents with characteristic deformities across the involved joints, requiring
individualized treatment. Early stages may respond well to aggressive conservative management, yet more severe AAFD necessitates prompt surgical therapy to halt the progression of the disease to
stages requiring more complex procedures. We present the most current diagnostic and therapeutic approaches to AAFD, based on the most pertinent literature and our own experience and
As the name suggests, adult-acquired flatfoot occurs once musculoskeletal maturity is reached, and it can present for a number of reasons, though one stands out among the others. While fractures,
dislocations, tendon lacerations, and other such traumatic events do contribute to adult-acquired flatfoot as a significant lower extremity disorder, as mentioned above, damage to the posterior
tibial tendon is most often at the heart of adult-acquired flatfoot. One study further elaborates on the matter by concluding that ?60% of patients [presenting with posterior tibial tendon damage and
adult-acquired flatfoot] were obese or had diabetes mellitus, hypertension, previous surgery or trauma to the medial foot, or treatment with steroids?.
PTTD begins with a gradual stretching and loss of strength of the posterior tibial tendon which is the most important tendon supporting the arch of the human foot. Left untreated, this tendon will
continue to lengthen and eventually rupture, leading to a progressive visible collapse of the arch of the foot. In the early stages, patients with PTTD will notice a pain and swelling along the inner
ankle and arch. Many times, they are diagnosed with ?tendonitis? of the inner ankle. If the foot and ankle are not properly supported during this early phase, the posterior tibial tendon can rupture
and devastating consequences will occur to the foot and ankle structure. The progressive adult acquired flatfoot deformity will cause the heel to roll inward in a ?valgus? or pronated direction while
the forefoot will rotate outward causing a ?duckfooted? walking pattern. Eventually, significant arthritis can occur in the joints of the foot, the ankle and even the knee. Early diagnosis and
treatment is critical so if you have noticed that one, or both, of your feet has become flatter in recent times come in and have it checked out.
The history and physical examination are probably the most important tools the physician uses to diagnose this problem. The wear pattern on your shoes can offer some helpful clues. Muscle testing
helps identify any areas of weakness or muscle impairment. This should be done in both the weight bearing and nonweight bearing positions. A very effective test is the single heel raise. You will be
asked to stand on one foot and rise up on your toes. You should be able to lift your heel off the ground easily while keeping the calcaneus (heel bone) in the middle with slight inversion (turned
inward). X-rays are often used to study the position, shape, and alignment of the bones in the feet and ankles. Magnetic resonance (MR) imaging is the imaging modality of choice for evaluating the
posterior tibial tendon and spring ligament complex.
Non surgical Treatment
PTTD is a progressive condition. Early treatment is needed to prevent relentless progression to a more advanced disease which can lead to more problems for that affected foot. In general, the
treatments include rest. Reducing or even stopping activities that worsen the pain is the initial step. Switching to low-impact exercise such as cycling, elliptical trainers, or swimming is helpful.
These activities do not put a large impact load on the foot. Ice. Apply cold packs on the most painful area of the posterior tibial tendon frequently to keep down the swelling. Placing ice over the
tendon immediately after completing an exercise helps to decrease the inflammation around the tendon.
Nonsteroidal Anti-inflammatory Medication (NSAIDS). Drugs, such as arcoxia, voltaren and celebrex help to reduce pain and inflammation. Taking such medications prior to an exercise activity helps to
limit inflammation around the tendon. However, long term use of these drugs can be harmful to you with side effects including peptic ulcer disease and renal impairment or failure. Casting. A short
leg cast or walking boot may be used for 6 to 8 weeks in the acutely painful foot. This allows the tendon to rest and the swelling to go down. However, a cast causes the other muscles of the leg to
atrophy (decrease in strength) and thus is only used if no other conservative treatment works. Most people can be helped with orthotics and braces. An orthotic is a shoe insert. It is the most common
non-surgical treatment for a flatfoot and it is very safe to use. A custom orthotic is required in patients who have moderate to severe changes in the shape of the foot. Physiotherapy helps to
strengthen the injured tendon and it can help patients with mild to moderate disease of the posterior tibial tendon.
If initial conservative therapy of posterior tibial tendon insufficiency fails, surgical treatment is considered. Operative treatment of stage 1 disease involves release of the tendon sheath,
tenosynovectomy, debridement of the tendon with excision of flap tears, and repair of longitudinal tears. A short-leg walking cast is worn for 3 weeks postoperatively. Teasdall and Johnson reported
complete relief of pain in 74% of 14 patients undergoing this treatment regimen for stage 1 disease. Surgical debridement of tenosynovitis in early stages is believed to possibly prevent progression
of disease to later stages of dysfunction.