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
Women are affected by Adult Acquired Flatfoot four times more frequently than men. Adult Flatfoot generally occurs in middle to older age people. Most people who acquire the condition already have
flat feet. One arch begins to flatten more, then pain and swelling develop on the inside of the ankle. This condition generally affects only one foot. It is unclear why women are affected more often
than men. But factors that may increase your risk of Adult Flatfoot include diabetes, hypertension, and obesity.
Depending on the cause of the flatfoot, a patient may experience one or more of the different symptoms here. Pain along the course of the posterior tibial tendon which lies on the inside of the foot
and ankle. This can be associated with swelling on the inside of the ankle. Pain that is worse with activity. High intensity or impact activities, such as running, can be very difficult. Some
patients can have difficulty walking or even standing for long periods of time. When the foot collapses, the heel bone may shift position and put pressure on the outside ankle bone (fibula). This can
cause pain on the outside of the ankle. Arthritis in the heel also causes this same type of pain. Patients with an old injury or arthritis in the middle of the foot can have painful, bony bumps on
the top and inside of the foot. These make shoewear very difficult. Occasionally, the bony spurs are so large that they pinch the nerves which can result in numbness and tingling on the top of the
foot and into the toes. Diabetics may only notice swelling or a large bump on the bottom of the foot. Because their sensation is affected, people with diabetes may not have any pain. The large bump
can cause skin problems and an ulcer (a sore that does not heal) may develop if proper diabetic shoewear is not used.
In the early stages of dysfunction of the posterior tibial tendon, most of the discomfort is located medially along the course of the tendon and the patient reports fatigue and aching on the
plantar-medial aspect of the foot and ankle. Swelling is common if the dysfunction is associated with tenosynovitis. As dysfunction of the tendon progresses, maximum pain occurs laterally in the
sinus tarsi because of impingement of the fibula against the calcaneus. With increasing deformity, patients report that the shape of the foot changes and that it becomes increasingly difficult to
wear shoes. Many patients no longer report pain in the medial part of the foot and ankle after a complete rupture of the posterior tibial tendon has occurred; instead, the pain is located laterally.
If a fixed deformity has not occurred, the patient may report that standing or walking with the hindfoot slightly inverted alleviates the lateral impingement and relieves the pain in the lateral part
of the foot.
Non surgical Treatment
Because of the progressive nature of PTTD, early treatment is critical. If treated soon enough, symptoms may resolve without the need for surgery and progression of the condition can be stopped. If
left untreated, PTTD may create an extremely flat foot, painful arthritis in the foot and ankle, and will limit your ability to walk, run, and other activities. Your podiatrist may recommend one or
more of these non-surgical treatments to manage your PTTD. Orthotic devices or bracing. To give your arch the support it needs, your foot and ankle surgeon may recommend an ankle brace or a custom
orthotic device that fits into your shoe to support the arch. Immobilization. A short-leg cast or boot may be worn to immobilize the foot and allow the tendon to heal. Physical therapy. Ultrasound
therapy and stretching exercises may help rehabilitate the tendon and muscle following immobilization. Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the
pain and inflammation. Shoe modifications. Your foot and ankle surgeon may recommend changes in your footwear.
If conservative treatment fails surgical intervention is offered. For a Stage 1 deformity a posterior tibial tendon tenosynovectomy (debridement of the tendon) or primary repair may be indicated. For
Stage 2 a combination of Achilles lengthening with bone cuts, calcaneal osteotomies, and tendon transfers is common. Stage 2 flexible PTTD is the most common stage patients present with for
treatment. In Stage 3 or 4 PTTD isolated fusions, locking two or more joints together, maybe indicated. All treatment is dependent on the stage and severity at presentation with the goals and
activity levels of the patient in mind. Treatment is customized to the individual patient needs.