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 Obesity - Overtime if your body is carrying those extra pounds, you can potentially injure your feet. The extra weight puts pressure on the ligaments that support your feet. Also being over weight can lead to type two diabetes which also can attribute to AAFD. Diabetes - Diabetes can also play a role in Adult Acquired Flatfoot Deformity. Diabetes can cause damage to ligaments, which support your feet and other bones in your body. In addition to damaged ligaments, uncontrolled diabetes can lead to ulcers on your feet. When the arches fall in the feet, the front of the foot is wider, and outer aspects of the foot can start to rub in your shoe wear. Patients with uncontrolled diabetes may not notice or have symptoms of pain due to nerve damage. Diabetic patient don?t see they have a problem, and other complications occur in the feet such as ulcers and wounds. Hypertension - High blood pressure cause arteries narrow overtime, which could decrease blood flow to ligaments. The blood flow to the ligaments is what keeps the foot arches healthy, and supportive. Arthritis - Arthritis can form in an old injury overtime this can lead to flatfeet as well. Arthritis is painful as well which contributes to the increased pain of AAFD. Injury - Injuries are a common reason as well for AAFD. Stress from impact sports. Ligament damage from injury can cause the bones of the foot to fallout of ailment. Overtime the ligaments will tear and result in complete flattening of feet. Symptoms The symptoms of PTTD may include pain, swelling, a flattening of the arch, and an inward rolling of the ankle. As the condition progresses, the symptoms will change. For example, when PTTD initially develops, there is pain on the inside of the foot and ankle (along the course of the tendon). In addition, the area may be red, warm, and swollen. Later, as the arch begins to flatten, there may still be pain on the inside of the foot and ankle. But at this point, the foot and toes begin to turn outward and the ankle rolls inward. As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. The tendon has deteriorated considerably and arthritis often develops in the foot. In more severe cases, arthritis may also develop in the ankle. 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 Get treated early. There is no recommended home treatment. While in stage one of the deformity, rest, a cast, and anti-inflammatory therapy can help you find relief. This treatment is followed by creating custom-molded foot orthoses and orthopedic footwear. These customized items are critical in maintaining the stability of the foot and ankle. Once the tendon has stretched and deformity is visible, the chances of success for non-surgical treatment are significantly lower. In a small percentage of patients, total immobilization may arrest the progression of the deformity. A long-term brace known as an ankle foot orthosis is required to keep the deformity from progressing. The Richie Brace, a type of ankle foot orthosis, shows significant success as a treatment for stage two posterior tibial dysfunction. It is a sport-style brace connected to a custom corrected foot orthodic that fits into most lace-up footwear (including athletic shoes). It is also light weight and more cosmetically appealing than traditionally prescribed ankle foot orthosis. The Arizona Brace, California Brace or Gauntlet Brace may also be recommended depending on your needs. Surgical Treatment If conservative treatments don?t work, your doctor may recommend surgery. Several procedures can be used to treat posterior tibial tendon dysfunction; often more than one procedure is performed at the same time. Your doctor will recommend a specific course of treatment based on your individual case. Surgical options include. Tenosynovectomy. In this procedure, the surgeon will clean away (debride) and remove (excise) any inflamed tissue surrounding the tendon. Osteotomy. This procedure changes the alignment of the heel bone (calcaneus). The surgeon may sometimes have to remove a portion of the bone. Tendon transfer: This procedure uses some fibers from another tendon (the flexor digitorum longus, which helps bend the toes) to repair the damaged posterior tibial tendon. Lateral column lengthening, In this procedure, the surgeon places a small wedge-shaped piece of bone into the outside of the calcaneus. This helps realign the bones and recreates the arch. Arthrodesis. This procedure welds (fuses) one or more bones together, eliminating movement in the joint. This stabilizes the hindfoot and prevents the condition from progressing further.