A variety of foot problems can lead to adult acquired flatfoot
deformity (AAFD), a condition that results in a fallen arch with the foot
pointed outward. Most people - no matter what the cause of their flatfoot - can be helped with orthotics and braces. In patients who have tried orthotics and braces without any relief, surgery can be
a very effective way to help with the pain and deformity. This article provides a brief overview of the problems that can result in AAFD. Further details regarding the most common conditions that
cause an acquired flatfoot and their treatment options are provided in separate articles. Links to those articles are provided.
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.
Pain and swelling behind the inside of your ankle and along your instep. You may be tender behind the inner ankle where the posterior tibial tendon courses and occasionally get burning, shooting,
tingling or stabbing pain as a result of inflammation of the nerve inside the tarsal tunnel. Difficulty walking, the inability to walk long distances and a generalised ache while walking even short
distances. This may probably become more pronounced at the end of each day. Change in foot shape, sometimes your tendon stretches out, this is due to weakening of the tendon and ligaments. When this
occurs, the arch in your foot flattens and a flatfoot deformity occurs, presenting a change in foot shape. Inability to tip-toe, a way of diagnosing Posterior Tibial Tendon Dysfunction is difficulty
or inability to ?heel rise? (stand on your toes on one foot). Your tibialis posterior tendon enables you to perform this manoeuvre effectively. You may also experience pain upon attempting to perform
a heel rise.
Clinicians need to recognize the early stage of this syndrome which includes pain, swelling, tendonitis and disability. The musculoskeletal portion of the clinical exam can help determine the stage
of the disease. It is important to palpate the posterior tibial tendon and test its muscle strength. This is tested by asking patient to plantarflex and invert the foot. Joint range of motion is
should be assessed as well. Stiffness of the joints may indicate longstanding disease causing a rigid deformity. A weightbearing examination should be performed as well. A complete absence of the
medial longitudinal arch is often seen. In later stages the head of the talus bone projects outward to the point of a large "lump" in the arch. Observing the patient's feet from behind shows a
significant valgus rotation of the heel. From behind, the "too many toes" sign may be seen as well. This is when there is abducution of the forefoot in the transverse plane allowing the toes to be
seen from behind. Dysfunction of the posterior tibial tendon can be assessed by asking the patient to stand on his/her toes on the affected foot. If they are unable to, this indicates the disease is
in a more advanced stage with the tendon possibly completely ruptured.
Non surgical Treatment
Options range from shoe inserts, orthotics, bracing and physical therapy for elderly and/or inactive patients to reconstructive surgical procedures in those wishing to remain more active. These
treatments restore proper function and alignment of the foot by replacing the damaged muscle tendon unit with an undamaged, available and expendable one, lengthening the contracted Achilles tendon
and realigning the Os Calcis, or heel bone, while preserving the joints of the hindfoot. If this condition is not recognized before it reaches advanced stages, a fusion of the hindfoot or even the
ankle is necessary. Typically this is necessary in elderly individuals with advanced cases that cannot be improved with bracing.
Although non-surgical treatments can successfully manage the symptoms, they do not correct the underlying problem. It can require a life-long commitment to wearing the brace during periods of
increased pain or activity demands. This will lead a majority of patients to choose surgical correction of the deformity, through Reconstructive Surgery. All of the considerations that were extremely
important during the evaluation stage become even more important when creating a surgical plan. Generally, a combination of procedures are utilized in the same setting, to allow full correction of
the deformity. Many times, this can be performed as a same-day surgery, without need for an overnight hospital stay. However, one or two day hospital admissions can be utilized to help manage the
post-operative pain. Although the recovery process can require a significant investment of time, the subsequent decades of improved function and activity level, as well as decreased pain, leads to a
substantial return on your investment.