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 investigations.
Adult flatfoot typically occurs very gradually. If often develops in an obese person who already has somewhat flat feet. As the person ages, the tendons and ligaments that support the foot begin to
lose their strength and elasticity.
Pain along the inside of the foot and ankle, where the tendon lies. This may or may not be associated with swelling in the area. Pain that is worse with activity. High-intensity or high-impact
activities, such as running, can be very difficult. Some patients can have trouble walking or standing for a long time. Pain on the outside of the ankle. When the foot collapses, the heel bone may
shift to a new position outwards. This can put pressure on the outside ankle bone. The same type of pain is found in arthritis in the back of the foot. Asymmetrical collapsing of the medial arch on
the affected side.
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
Conservative (nonoperative) care is advised at first. A simple modification to your shoe may be all that???s needed. Sometimes purchasing shoes with a good arch support is sufficient. For other
patients, an off-the-shelf (prefabricated) shoe insert works well. The orthotic is designed specifically to position your foot in good alignment. Like the shoe insert, the orthotic fits inside the
shoe. These work well for mild deformity or symptoms. Over-the-counter pain relievers or antiinflammatory drugs such as ibuprofen may be helpful. If symptoms are very severe, a removable boot or cast
may be used to rest, support, and stabilize the foot and ankle while still allowing function. Patients with longer duration of symptoms or greater deformity may need a customized brace. The brace
provides support and limits ankle motion. After several months, the brace is replaced with a foot orthotic. A physical therapy program of exercise to stretch and strengthen the foot and leg muscles
is important. The therapist will also show you how to improve motor control and proprioception (joint sense of position). These added features help prevent and reduce injuries.
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