Originally known as posterior tibial tendon dysfunction or insufficiency, adult-acquired flatfoot
deformity encompasses a wide range of deformities. These
deformities vary in location, severity, and rate of progression. Establishing a diagnosis as early as possible is one of the most important factors in treatment. Prompt early, aggressive nonsurgical
management is important. A patient in whom such treatment fails should strongly consider surgical correction to avoid worsening of the deformity. In all four stages of deformity, the goal of surgery
is to achieve proper alignment and maintain as much flexibility as possible in the foot and ankle complex. However, controversy remains as to how to manage flexible deformities, especially those that
Adult acquired flatfoot is caused by inflammation and progressive weakening of the major tendon that it is responsible for supporting the arch of the foot. This condition will commonly be accompanied
by swelling and pain on the inner portion of the foot and ankle. Adult acquired flatfoot is more common in women and overweight individuals. It can also be seen after an injury to the foot and ankle.
If left untreated the problem may result in a vicious cycle, as the foot becomes flatter the tendon supporting the arch structure becomes weaker and more and more stretched out. As the tendon becomes
weaker, the foot structure becomes progressively flatter. Early detection and treatment is key, as this condition can lead to chronic swelling and pain.
In many cases, adult flatfoot causes no pain or problems. In others, pain may be severe. Many people experience aching pain in the heel and arch and swelling along the inner side of the foot.
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
The adult acquired flatfoot is best treated early. Accurate assessment by your doctor will determine which treatment is suitable for you. Reduce your level of activity and follow the RICE regime. R -
rest as often as you are able. Refrain from activity that will worsen your condition, such as sports and walking. I - ice, apply to the affected area, ensure you protect the area from frostbite by
applying a towel over the foot before using the ice pack. C - compression, a Tubigrip or elasticated support bandage may be
applied to relieve symptoms and ease pain and discomfort. E - elevate the affected foot to reduce painful swelling. You will be prescribed pain relief in the form of non-steroidal antiinflammatory
medications (if you do not suffer with allergies or are asthmatic). Immobilisation of your affected foot - this will involve you having a below the knee cast for four to eight weeks. In certain
circumstances it is possible for you to have a removable boot instead of a cast. A member of the foot and ankle team will advise as to whether this option is suitable for you. Footwear is important -
it is advisable to wear flat sturdy lace-up shoes, for example, trainers or boots. This will not only support your foot, but will also accommodate orthoses (shoe inserts).
Many operations are available for the treatment of dysfunction of the posterior tibial tendon after a thorough program of non-operative treatment has failed. The type of operation that is selected is
determined by the age, weight, and level of activity of the patient as well as the extent of the deformity. The clinical stages outlined previously are a useful guide to operative care (Table I). In
general, the clinician should perform the least invasive procedure that will decrease pain and improve function. One should consider the effects of each procedure, particularly those of arthrodesis,
on the function of the rest of the foot and ankle.