For many adults, years of wear and tear on the feet can lead to a gradual and potentially debilitating collapse of the arch. However, a new treatment approach based on early surgical intervention is
achieving a high rate of longterm success. Based on results of clinical studies of adults with flat feet, we now believe that reconstructive surgery in the early stages of the condition can prevent
complications later on. Left untreated, the arch eventually will collapse, causing debilitating arthritis in the foot and ankle. At this end stage, surgical fusions are often required to stabilize
Damage to the posterior tendon from overuse is the most common cause for adult acquired flatfoot. Running, walking, hiking, and climbing stairs are activities that add stress to this tendon, and this
overuse can lead to damage. Obesity, previous ankle surgery or trauma, diabetes (Charcot foot), and rheumatoid arthritis are other common risk factors.
Often, this condition is only present in one foot, but it can affect both. Adult acquired flatfoot symptoms vary, but can swelling of the foot's inner side and aching heel and arch pain. Some
patients experience no pain, but others may experience severe pain. Symptoms may increase during long periods of standing, resulting in fatigue. Symptoms may change over time as the condition
worsens. The pain may move to the foot's outer side, and some patients may develop arthritis in the ankle and foot.
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
Nonoperative therapy for posterior tibial tendon dysfunction has been shown to yield 67% good-to-excellent results in 49 patients with stage 2 and 3 deformities. A rigid UCBL orthosis with a medial
forefoot post was used in nonobese patients with flexible heel deformities correctible to neutral and less than 10? of forefoot varus. A molded ankle foot orthosis was used in obese patients with
fixed deformity and forefoot varus greater than 10?. Average length of orthotic use was 15 months. Four patients ultimately elected to have surgery. The authors concluded that orthotic management is
successful in older low-demand patients and that surgical treatment can be reserved for those patients who fail nonoperative treatment.
Stage two deformities are less responsive to conservative therapies that can be effective in mild deformities. Bone procedures are necessary at this stage in order to recreate the arch and stabilize
the foot. These procedures include isolated fusion procedures, bone grafts, and/or the repositioning of bones through cuts called osteotomies. The realigned bones are generally held in place with
screws, pins, plates, or staples while the bone heals. A tendon transfer may or may not be utilized depending on the condition of the posterior tibial tendon. Stage three deformities are better
treated with surgical correction, in healthy patients. Patients that are unable to tolerate surgery or the prolonged healing period are better served with either arch supports known as orthotics or
bracing such as the Richie Brace. Surgical correction at this stage usually requires fusion procedures such as a triple or double arthrodesis. This involves fusing the two or three major bones in the
back of the foot together with screws or pins. The most common joints fused together are the subtalar joint, talonavicular joint, and the calcaneocuboid joint. By fusing the bones together the
surgeon is able to correct structural deformity and alleviate arthritic pain. Tendon transfer procedures are usually not beneficial at this stage. Stage four deformities are treated similarly but
with the addition of fusing the ankle joint.