may be due to multiple problems including a dysfunctional posterior tibial tendon (PTT), hypermobility and
ligamentous laxity, or possibly a coalition that becomes symptomatic. For a vast majority of patients, posterior tibial tendon dysfunction (PTTD) is the cause of symptomatic flatfoot and is the main
trigger of surgical reconstruction in flatfoot. The common presenting scenario for adult flatfoot is a case of unilateral flatfoot with pain. Patients will often confirm they always had flat feet but
have noticed increased pain and additional collapse in the past few months to years. They may also note increased swelling and a possible concern over one foot increasing in shoe size. After a
comprehensive dermatologic, neurologic and vascular assessment, one should direct his or her attention to the musculoskeletal portion of the exam. It is key to examine the foot and leg as a whole in
order to determine the proper procedure and consider each phase of the corrective surgery.
There are multiple factors contributing to the development of this problem. Damage to the nerves, ligaments, and/or tendons of the foot can cause subluxation (partial dislocation) of the subtalar or
talonavicular joints. Bone fracture is a possible cause. The resulting joint deformity from any of these problems can lead to adult-acquired flatfoot deformity. Dysfunction of the posterior tibial
tendon has always been linked with adult-acquired flatfoot deformity (AAFD). The loss of active and passive pull of the tendon alters the normal biomechanics of the foot and ankle. The reasons for
this can be many and varied as well. Diabetes, high blood pressure, and prolonged use of steroids are some of the more common causes of adult-acquired flatfoot deformity (AAFD) brought on by
impairment of the posterior tibialis tendon. Overstretching or rupture of the tendon results in tendon and muscle imbalance in the foot leading to adult-acquired flatfoot deformity (AAFD). Rheumatoid
arthritis is one of the more common causes. About half of all adults with this type of arthritis will develop adult flatfoot deformity over time. In such cases, the condition is gradual and
progressive. Obesity has been linked with this condition. Loss of blood supply for any reason in the area of the posterior tibialis tendon is another factor. Other possible causes include bone
fracture or dislocation, a torn or stretched tendon, or a neurologic condition causing weakness.
Often, this condition is only present in one foot, but it can affect both. Adult acquired flatfoot symptoms vary, but can swelling of the foot's inner side and aching heel and arch pain. Some
patients experience no pain, but others may experience severe pain. Symptoms may increase during long periods of standing, resulting in fatigue. Symptoms may change over time as the condition
worsens. The pain may move to the foot's outer side, and some patients may develop arthritis in the ankle and foot.
Posterior Tibial Tendon Dysfunction is diagnosed with careful clinical observation of the patient?s gait (walking), range of motion testing for the foot and ankle joints, and diagnostic imaging.
People with flatfoot deformity walk with the heel angled outward, also called over-pronation. Although it is normal for the arch to impact the ground for shock absorption, people with PTTD have an
arch that fully collapses to the ground and does not reform an arch during the entire gait period. After evaluating the ambulation pattern, the foot and ankle range of motion should be tested.
Usually the affected foot will have decreased motion to the ankle joint and the hindfoot. Muscle strength may also be weaker as well. An easy test to perform for PTTD is the single heel raise where
the patient is asked to raise up on the ball of his or her effected foot. A normal foot type can lift up on the toes without pain and the heel will invert slightly once the person has fully raised
the heel up during the test. In early phases of PTTD the patient may be able to lift up the heel but the heel will not invert. An elongated or torn posterior tibial tendon, which is a mid to late
finding of PTTD, will prohibit the patient from fully rising up on the heel and will cause intense pain to the arch. Finally diagnostic imaging, although used alone cannot diagnose PTTD, can provide
additional information for an accurate diagnosis of flatfoot deformity. Xrays of the foot can show the practitioner important angular relationships of the hindfoot and forefoot which help diagnose
flatfoot deformity. Most of the time, an MRI is not needed to diagnose PTTD but is a tool that should be considered in advanced cases of flatfoot deformity. If a partial tear of the posterior tibial
tendon is of concern, then an MRI can show the anatomic location of the tear and the extensiveness of the injury.
Non surgical Treatment
Treatment of Adult Acquired Flatfoot Deformity depends on the stage of progression, as mentioned above paragraphs. Below we will outline a variety of different treatment options available. Orthotics
or bracing. To give your foot the arch the support it needs, your podiatrist or foot specialist may provide you with over the counter brace or a custom orthotic device that fits your shoe. Casting.
In some cases, a cast or boot is worn to stabilize the foot and to give the tendon time to heal. Physiotherapy. Ultrasound treatments and exercises may help rehab the tendon and muscles. Medications.
Over-the-counter (NSAIDS) such as ibuprofen can help reduce pain, inflammation and swelling associated with AAFD. Shoe Gear. Your podiatrist may suggest changes with your shoes you are wearing and
inserts you need in your shoe to help support your arch.
Flatfoot reconstruction (osteotomy). This is often recommended for flexible flatfoot condition. Flatfoot reconstruction involves cutting and shifting the heel bone into a more neutral position,
transferring the tendon used to flex the lesser toes (all but the big toe) to strengthen the posterior tibial tendon, and lengthening the calf muscle. Fusion (also known as triple arthrodesis).
Fusion involves fusing, or making stiff, three joints in the back of the foot the subtalar, talonavicular, and calcaneocuboid joints, to realign the foot and give it a more natural shape. Pins or
screws hold the area in place until it heals. Fusion is often recommended for a rigid flatfoot deformity or evidence of arthritis. Both of these surgeries can provide excellent pain relief and