Adult acquired flat foot
was first described in the late 1960s as something that occurred after trauma, as a result of a tear to the tibial
posterior tendon. However, by 1969 two doctors called Kettlekamp and Alexander described cases in which no trauma had taken place. They referred to the condition as "tibial posterior tendon
dysfunction" and this became known as the most common type of adult acquired flat foot.
The posterior tibial tendon, which connects the bones inside the foot to the calf, is responsible for supporting the foot during movement and holding up the arch. Gradual stretching and tearing of
the posterior tibial tendon can cause failure of the ligaments in the arch. Without support, the bones in the feet fall out of normal position, rolling the foot inward. The foot's arch will collapse
completely over time, resulting in adult acquired flatfoot. The ligaments and tendons holding up the arch can lose elasticity and strength as a result of aging. Obesity, diabetes, and hypertension
can increase the risk of developing this condition. Adult acquired flatfoot is seen more often in women than in men and in those 40 or older.
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.
First, both feet should be examined with the patient standing and the entire lower extremity visible. The foot should be inspected from above as well as from behind the patient, as valgus angulation
of the hindfoot is best appreciated when the foot is viewed from behind. Johnson described the so-called more-toes sign: with more advanced deformity and abduction of the forefoot, more of the
lateral toes become visible when the foot is viewed from behind. The single-limb heel-rise test is an excellent determinant of the function of the posterior tibial tendon. The patient is asked to
attempt to rise onto the ball of one foot while the other foot is suspended off the floor. Under normal circumstances, the posterior tibial muscle, which inverts and stabilizes the hindfoot, is
activated as the patient begins to rise onto the forefoot. The gastrocnemius-soleus muscle group then elevates the calcaneus, and the heel-rise is accomplished. With dysfunction of the posterior
tibial tendon, however, inversion of the heel is weak, and either the heel remains in valgus or the patient is unable to rise onto the forefoot. If the patient can do a single-limb heel-rise, the
limb may be stressed further by asking the patient to perform this maneuver repetitively.
Non surgical Treatment
Treatment of Adult Acquired Flatfoot Deformity depends on the stage of progression, as mentioned above paragraphs. Below we will outline a variety of different treatment options available. Orthotics
or bracing. To give your foot the arch the support it needs, your podiatrist or foot specialist may provide you with over the counter brace or a custom orthotic device that fits your shoe. Casting.
In some cases, a cast or boot is worn to stabilize the foot and to give the tendon time to heal. Physiotherapy. Ultrasound treatments and exercises may help rehab the tendon and muscles. Medications.
Over-the-counter (NSAIDS) such as ibuprofen can help reduce pain, inflammation and swelling associated with AAFD. Shoe Gear. Your podiatrist may suggest changes with your shoes you are wearing and
inserts you need in your shoe to help support your arch.
Surgery should only be done if the pain does not get better after a few months of conservative treatment. The type of surgery depends on the stage of the PTTD disease. It it also dictated by where
tendonitis is located and how much the tendon is damaged. Surgical reconstruction can be extremely complex. Some of the common surgeries include. Tenosynovectomy, removing the inflamed tendon sheath
around the PTT. Tendon Transfer, to augment the function of the diseased posterior tibial tendon with a neighbouring tendon. Calcaneo-osteotomy, sometimes the heel bone needs to be corrected to get a
better heel bone alignment. Fusion of the Joints, if osteoarthritis of the foot has set in, fusion of the joints may be necessary.