Over 60 Million Americans suffer from Adult Acquired Flatfoot
(AAF), otherwise known as
Posterior Tibial Tendon Dysfunction or PTTD. This condition generally occurs in adults from 40-65 years of age, and it usually only occurs in one foot, not both. The Posterior Tibial (PT) Tendon
courses along the inside part of the ankle and underneath the arch of the foot. It is the major supporting structure for the arch. Over time, the tendon becomes diseased, from overuse, and starts to
lose it's strength. As a result, the arch begins to collapse, placing further strain on the PT Tendon, leading to further decrease in tendon strength, which causes further collapse of the arch. This
is described as a progressive deformity because it will generally get worse over time.
Obesity - Overtime if your body is carrying those extra pounds, you can potentially injure your feet. The extra weight puts pressure on the ligaments that support your feet. Also being over weight
can lead to type two diabetes which also can attribute to AAFD. Diabetes - Diabetes can also play a role in Adult Acquired Flatfoot Deformity. Diabetes can cause damage to ligaments, which support
your feet and other bones in your body. In addition to damaged ligaments, uncontrolled diabetes can lead to ulcers on your feet. When the arches fall in the feet, the front of the foot is wider, and
outer aspects of the foot can start to rub in your shoe wear. Patients with uncontrolled diabetes may not notice or have symptoms of pain due to nerve damage. Diabetic patient don?t see they have a
problem, and other complications occur in the feet such as ulcers and wounds. Hypertension - High blood pressure cause arteries narrow overtime, which could decrease blood flow to ligaments. The
blood flow to the ligaments is what keeps the foot arches healthy, and supportive. Arthritis - Arthritis can form in an old injury overtime this can lead to flatfeet as well. Arthritis is painful as
well which contributes to the increased pain of AAFD. Injury - Injuries are a common reason as well for AAFD. Stress from impact sports. Ligament damage from injury can cause the bones of the foot to
fallout of ailment. Overtime the ligaments will tear and result in complete flattening of feet.
The first stage represents inflammation and symptoms originating from an irritated posterior tibial tendon, which is still functional. Stage two is characterized by a change in the alignment of the
foot noted on observation while standing (see above photos). The deformity is supple meaning the foot is freely movable and a ?normal? position can be restored by the examiner. Stage two is also
associated with the inability to perform a single-leg heel rise. The third stage is dysfunction of the posterior tibial tendon is a flatfoot deformity that becomes stiff because of arthritis.
Prolonged deformity causes irritation to the involved joints resulting in arthritis. The fourth phase is a flatfoot deformity either supple (stage two) or stiff (stage 3) with involvement of the
ankle joint. This occurs when the deltoid ligament, the major supporting structure on the inside of the ankle, fails to provide support. The ankle becomes unstable and will demonstrate a tilted
appearance on X-ray. Failure of the deltoid ligament results from an inward displacement of the weight bearing forces. When prolonged, this change can lead to ankle arthritis. The vast majority of
patients with acquired adult flatfoot deformity are stage 2 by the time they seek treatment from a physician.
Observe forefoot to hindfoot alignment. Do this with the patient sitting and the heel in neutral, and also with the patient standing. I like to put blocks under the forefoot with the heel in neutral
to see how much forefoot correction is necessary to help hold the hindfoot position. One last note is to check all joints for stiffness. In cases of prolonged PTTD or coalition, rigid deformity is
present and one must carefully check the joints of the midfoot and hindfoot for stiffness and arthritis in the surgical pre-planning.
Non surgical Treatment
Flatfoot deformity can be treated conservatively or with surgical intervention depending on the severity of the condition. When people notice their arches flattening, they should immediately avoid
non-supportive shoes such as flip-flops, sandals or thin-soled tennis shoes. Theses shoes will only worsen the flatfoot deformity and exacerbate arch pain. Next, custom orthotics are essential for
people with collapsed arches. Over-the-counter insoles only provide cushion and padding to the arch, whereas custom orthotics are fabricated to specifically fit the patient?s foot and provide support
in the arch where the posterior tibial tendon is unable to anymore. Use of custom orthotics in the early phases of flatfoot or PTTD can prevent worsening of symptoms and prevent further attenuation
or injury to the posterior tibial tendon. In more severe cases of flatfoot deformity an ankle foot orthosis (AFO) such as a Ritchie brace is needed. This brace provides more support to the arch and
hindfoot rather than an orthotic but can be bulky in normal shoegear. Additional treatment along with use of custom orthotics is use of non-steroidal anti-inflammatories (NSAIDS) such as Advil,
Motrin, or Ibuprofen which can decrease inflammation to the posterior tibial tendon. If pain is severe, the patient may need to be placed in a below the knee air walker boot for several weeks which
will allow the tendon to rest and heal, especially if a posterior tibial tendon tear is noted on MRI.
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.