Overview
Adult flatfoot refers to a deformity that develops after skeletal maturity is reached. Adult flatfoot should be differentiated from constitutional flatfoot, which is a common congenital non-pathologic foot morphology. There are numerous causes of acquired adult flatfoot, including fracture or dislocation, tendon laceration, tarsal coalition, arthritis, neuroarthropathy, neurologic weakness, and iatrogenic causes.
Causes
Posterior tibial tendon dysfunction is the most common cause of acquired adult flatfoot. Sometimes this can be a result of specific trauma, but usually the tendon becomes injured from wear and tear over time. This is more prevalent in individuals with an inherited flat foot but excessive weight, age, and level of activity are also contributing factors.
Symptoms
Initially, flatfoot deformity may not present with any symptoms. However, overtime as the tendon continues to function in an abnormal position, people with fallen arches will begin to have throbbing or sharp pain along the inside of the arch. Once the tendon and soft tissue around it elongates, there is no strengthening exercises or mechanism to shorten the tendon back to a normal position. Flatfoot can also occur in one or both feet. If the arch starts to slowly collapse in one foot and not the other, posterior tibial dysfunction (PTTD) is the most likely cause. People with flatfoot may only have pain with certain activities such as running or exercise in the early phase of PTTD. Pain may start from the arch and continue towards the inside part of the foot and ankle where the tendon courses from the leg. Redness, swelling and increased warmth may also occur. Later signs of PTTD include pain on the outside of the foot from the arch collapsing and impinging other joints. Arthritic symptoms such as painful, swollen joints in the foot and ankle may occur later as well due to the increased stress on the joints from working in an abnormal position for a long period of time.
Diagnosis
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
Non-surgical treatment includes rest and reducing your activity until the pain improves. Orthotics or bracing help support the tendon to reduce its pull along the arch, thus reducing pain. In moderate to severe cases, a below knee cast or walking boot may be needed to allow the tendon to rest completely and heal. Physical therapy is an integral part of the non-surgical treatment regimen to reduce inflammation and pain. Anti-inflammatory medication is often used as well. Many times evaluation of your current shoes is necessary to ensure you are wearing appropriate shoe gear to prevent re-injury.
Surgical Treatment
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.
Adult flatfoot refers to a deformity that develops after skeletal maturity is reached. Adult flatfoot should be differentiated from constitutional flatfoot, which is a common congenital non-pathologic foot morphology. There are numerous causes of acquired adult flatfoot, including fracture or dislocation, tendon laceration, tarsal coalition, arthritis, neuroarthropathy, neurologic weakness, and iatrogenic causes.
Causes
Posterior tibial tendon dysfunction is the most common cause of acquired adult flatfoot. Sometimes this can be a result of specific trauma, but usually the tendon becomes injured from wear and tear over time. This is more prevalent in individuals with an inherited flat foot but excessive weight, age, and level of activity are also contributing factors.
Symptoms
Initially, flatfoot deformity may not present with any symptoms. However, overtime as the tendon continues to function in an abnormal position, people with fallen arches will begin to have throbbing or sharp pain along the inside of the arch. Once the tendon and soft tissue around it elongates, there is no strengthening exercises or mechanism to shorten the tendon back to a normal position. Flatfoot can also occur in one or both feet. If the arch starts to slowly collapse in one foot and not the other, posterior tibial dysfunction (PTTD) is the most likely cause. People with flatfoot may only have pain with certain activities such as running or exercise in the early phase of PTTD. Pain may start from the arch and continue towards the inside part of the foot and ankle where the tendon courses from the leg. Redness, swelling and increased warmth may also occur. Later signs of PTTD include pain on the outside of the foot from the arch collapsing and impinging other joints. Arthritic symptoms such as painful, swollen joints in the foot and ankle may occur later as well due to the increased stress on the joints from working in an abnormal position for a long period of time.
Diagnosis
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
Non-surgical treatment includes rest and reducing your activity until the pain improves. Orthotics or bracing help support the tendon to reduce its pull along the arch, thus reducing pain. In moderate to severe cases, a below knee cast or walking boot may be needed to allow the tendon to rest completely and heal. Physical therapy is an integral part of the non-surgical treatment regimen to reduce inflammation and pain. Anti-inflammatory medication is often used as well. Many times evaluation of your current shoes is necessary to ensure you are wearing appropriate shoe gear to prevent re-injury.
Surgical Treatment
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.
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