Adult flatfoot (adult acquired flatfoot) or posterior tibial tendon
(PTTD) is a common pathology presented to foot and ankle specialists. PTTD is characterized by a valgus (everted) hindfoot, flattening of the longitudinal arch of the foot (collapse)
and abduction of the forefoot. This is a progressive deformity that begins flexible and can become rigid over time. The posterior tibial tendon (PT) is one of the main supporting structures of the
foot arch. Changes within this tendon cause flattening of the foot. There are four stages of this deformity that begins flexible and progressives, with no treatment, to a rigid deformity and with
time may involve the ankle joint. Patients usually present with pain in the foot or ankle stating the ankle is rolling. Its also common for patients to state they have difficulty walking barefoot.
Pain is exacerbated after physical activities. Pain is usually isolated to the inside of the foot along the course of the PT tendon.
As the name suggests, adult-acquired flatfoot occurs once musculoskeletal maturity is reached, and it can present for a number of reasons, though one stands out among the others. While fractures,
dislocations, tendon lacerations, and other such traumatic events do contribute to adult-acquired flatfoot as a significant lower extremity disorder, as mentioned above, damage to the posterior
tibial tendon is most often at the heart of adult-acquired flatfoot. One study further elaborates on the matter by concluding that ?60% of patients [presenting with posterior tibial tendon damage and
adult-acquired flatfoot] were obese or had diabetes mellitus, hypertension, previous surgery or trauma to the medial foot, or treatment with steroids?.
The symptom most often associated with AAF is PTTD, but it is important to see this only as a single step along a broader continuum. The most important function of the PT tendon is to work in synergy
with the peroneus longus to stabilize the midtarsal joint (MTJ). When the PT muscle contracts and acts concentrically, it inverts the foot, thereby raising the medial arch. When stretched under
tension, acting eccentrically, its function can be seen as a pronation retarder. The integrity of the PT tendon and muscle is crucial to the proper function of the foot, but it is far from the lone
actor in maintaining the arch. There is a vital codependence on a host of other muscles and ligaments that when disrupted leads to an almost predictable loss in foot architecture and subsequent
The diagnosis of tibialis posterior dysfunction is essentially clinical. However, plain radiographs of the foot and ankle are useful for assessing the degree of deformity and to confirm the presence
or absence of degenerative changes in the subtalar and ankle articulations. The radiographs are also useful to exclude other causes of an acquired flatfoot deformity. The most useful radiographs are
bilateral anteroposterior and lateral radiographs of the foot and a mortise (true anteroposterior) view of the ankle. All radiographs should be done with the patient standing. In most cases we see no
role for magnetic resonance imaging or ultrasonography, as the diagnosis can be made clinically.
Non surgical Treatment
A patient who has acute tenosynovitis has pain and swelling along the medial aspect of the ankle. The patient is able to perform a single-limb heel-rise test but has pain when doing so. Inversion of
the foot against resistance is painful but still strong. The patient should be managed with rest, the administration of appropriate anti-inflammatory medication, and immobilization. The injection of
corticosteroids is not recommended. Immobilization with either a rigid below-the-knee cast or a removable cast or boot may be used to prevent overuse and subsequent rupture of the tendon. A removable
stirrup-brace is not initially sufficient as it does not limit motion in the sagittal plane, a component of the pathological process. The patient should be permitted to walk while wearing the cast or
boot during the six to eight-week period of immobilization. At the end of that time, a decision must be made regarding the need for additional treatment. If there has been marked improvement, the
patient may begin wearing a stiff-soled shoe with a medial heel-and-sole wedge to invert the hindfoot. If there has been only mild or moderate improvement, a longer period in the cast or boot may be
For patients with a more severe deformity, or significant symptoms that do not respond to conservative treatment, surgery may be necessary. There are several procedures available depending on the
nature of your condition. Ligament and muscle lengthening, removal of inflamed tendon lining, transferring of a nearby tendon to re-establish an arch, and bone realignment and fusion are examples of
surgical options to help with a painful flatfoot condition. Surgery can be avoided when symptoms are addressed early. If you are feeling ankle pain or notice any warmth, redness or swelling in your
foot, contact us immediately. We can create a tailored treatment plan to resolve your symptoms and prevent future problems.