Overview Adult acquired flatfoot deformity (AAFD or AAF) is a progressive, symptomatic deformity resulting from gradual stretch of the posterior tibial tendon as well as other ligaments supporting the arch of the foot. AAFD develops after skeletal maturity, May also be referred to as posterior tibial tendon dysfunction (PTTD), although due to the complexity of the disorder AAFD is more appropriate. Significant ligamentous rupture occurs as the deformity progresses. Involved ligaments include the spring ligament, the superficial deltoid ligament, the plantar fascia, and the long and short plantar ligaments. Unilateral AAFD is more common than bilateral AAFD. Causes 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. Symptoms At first you may notice pain and swelling along the medial (big toe) side of the foot. This is where the posterior tibialis tendon travels from the back of the leg under the medial ankle bone to the foot. As the condition gets worse, tendon failure occurs and the pain gets worse. Some patients experience pain along the lateral (outside) edge of the foot, too. You may find that your feet hurt at the end of the day or after long periods of standing. Some people with this condition have trouble rising up on their toes. They may be unable to participate fully in sports or other recreational activities. Diagnosis There are four stages of adult-acquired flatfoot deformity (AAFD). The severity of the deformity determines your stage. For example, Stage I means there is a flatfoot position but without deformity. Pain and swelling from tendinitis is common in this stage. Stage II there is a change in the foot alignment. This means a deformity is starting to develop. The physician can still move the bones back into place manually (passively). Stage III adult-acquired flatfoot deformity (AAFD) tells us there is a fixed deformity. This means the ankle is stiff or rigid and doesn???t move beyond a neutral (midline) position. Stage IV is characterized by deformity in the foot and the ankle. The deformity may be flexible or fixed. The joints often show signs of degenerative joint disease (arthritis). Non surgical Treatment PTTD is a progressive condition. Early treatment is needed to prevent relentless progression to a more advanced disease which can lead to more problems for that affected foot. In general, the treatments include rest. Reducing or even stopping activities that worsen the pain is the initial step. Switching to low-impact exercise such as cycling, elliptical trainers, or swimming is helpful. These activities do not put a large impact load on the foot. Ice. Apply cold packs on the most painful area of the posterior tibial tendon frequently to keep down the swelling. Placing ice over the tendon immediately after completing an exercise helps to decrease the inflammation around the tendon. Nonsteroidal Anti-inflammatory Medication (NSAIDS). Drugs, such as arcoxia, voltaren and celebrex help to reduce pain and inflammation. Taking such medications prior to an exercise activity helps to limit inflammation around the tendon. However, long term use of these drugs can be harmful to you with side effects including peptic ulcer disease and renal impairment or failure. Casting. A short leg cast or walking boot may be used for 6 to 8 weeks in the acutely painful foot. This allows the tendon to rest and the swelling to go down. However, a cast causes the other muscles of the leg to atrophy (decrease in strength) and thus is only used if no other conservative treatment works. Most people can be helped with orthotics and braces. An orthotic is a shoe insert. It is the most common non-surgical treatment for a flatfoot and it is very safe to use. A custom orthotic is required in patients who have moderate to severe changes in the shape of the foot. Physiotherapy helps to strengthen the injured tendon and it can help patients with mild to moderate disease of the posterior tibial tendon. Surgical Treatment If conservative treatment fails surgical intervention is offered. For a Stage 1 deformity a posterior tibial tendon tenosynovectomy (debridement of the tendon) or primary repair may be indicated. For Stage 2 a combination of Achilles lengthening with bone cuts, calcaneal osteotomies, and tendon transfers is common. Stage 2 flexible PTTD is the most common stage patients present with for treatment. In Stage 3 or 4 PTTD isolated fusions, locking two or more joints together, maybe indicated. All treatment is dependent on the stage and severity at presentation with the goals and activity levels of the patient in mind. Treatment is customized to the individual patient needs.