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Adult Flatfoot
By William T. DeCarbo, DPM

William T. DeCarbo, DPM

Adult flatfoot (adult acquired flatfoot) or posterior tibial tendon dysfunction (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. (1,2) Patients usually present with pain in the foot or ankle stating the “ankle” is rolling. It’s 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.

Initial treatment is based on the degree of deformity and flexibility at initial presentation. Conservative treatment includes orthotics or ankle foot orthoses (AFO) to support the posterior tibial tendon (PT) and the longitudinal arch, anti-inflammatories to help reduce pain and inflammation, activity modification which may include immobilization of the foot and physical therapy to help strengthen and rehabilitate the tendon.

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 (3) 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. (4)

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.

Dr. William T. DeCarbo is a Fellowship Trained Foot & Ankle Surgeon, Private Practice with The Orthopedic Group. For more information, call any of The Orthopedic Group office locations:
Mt Lebanon – (412) 276-7022; Charleroi – (724) 483-4880; Belle Vernon – (724) 379-5802; Uniontown – (724) 425-0300; Monongahela - (724) 483-3228; Jefferson Hills - (412) 384-2240. Visit the website at theorthopedicgroup.com.

1. Johnson KA, Strom DE. Tibialis Posterior Tendon Dysfunction. CLin Orthop Relat Res 1989;(239):196-206.
2. Myerson MS. Adult Acquired Flatfoot Deformity: Treatment of Dysfunction of the Posterior Tibial Tendon. Instr Course Lect 1997;46:393-405.
3. Aronow MS. Triceps Surae Contractures Associated with Posterior Tibial Tendon Dysfunction. Tech Orthop 2000;15:164-73.
4. Johnson JE, Cohen BE, DiGiovanni BF, et al. Subtalar Arthrodesis with Flexor Digitorum Longus Transfer and Spring Ligament Repair for Treatment of Posterior Tibial Tendon Insufficiency. Foot Ankle Int 2000;21(9):722-9.

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