The Treatment

Overview


Adult acquired flatfoot is a very serious condition that can lead to many secondary deformities, not only within the foot but also in the knees, hips and back. This presentation discusses a new scientifically proven procedure that may be able to help realign and fix this problem at its root.Acquired Flat Feet






Causes


Flat feet causes greater pressure on the posterior tibial tendon than normal. As the person with flat feet ages, the muscles, tendons and ligaments weaken. Blood supplies diminish as arteries narrow. These conditions are magnified for obese patients because of their increased weight and atherosclerosis. Finally, the tendon gives out or tears. Most of the time, this is a slow process. Once the posterior tibial tendon and ligaments stretch, body weight causes the bones of the arch to move out of position. The foot rotates inward (pronation), the heel bone is tilted to the inside, and the arch appears collapsed. In some cases, the deformity progresses until the foot dislocates outward from the ankle joint.






Symptoms


The types of symptoms that may indicate Adult-Acquired Flat Foot Deformity include foot pain that worsens over time, loss of the arch, abnormal shoe wear (excessive wearing on the inner side of shoe from walking on the inner side of the foot) and an awkward appearance of the foot and ankle (when viewed from behind, heel and toes appear to go out to the side). It is important that we help individuals recognize the early symptoms of this condition, as there are many treatment options, depending upon the severity, the age of the patient, and the desired activity levels.






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


Initial treatment for most patients consists of rest and anti-inflammatory medications. This will help reduce the swelling and pain associated with the condition. The long term treatment for the problem usually involves custom made orthotics and supportive shoe gear to prevent further breakdown of the foot. ESWT(extracorporeal shock wave therapy) is a novel treatment which uses sound wave technology to stimulate blood flow to the tendon to accelerate the healing process. This can help lead to a more rapid return to normal activities for most patients. If treatment is initiated early in the process, most patients can experience a return to normal activities without the need for surgery.


Acquired Flat Feet






Surgical Treatment


Until recently, operative treatment was indicated for most patients with stage 2 deformities. However, with the use of potentially effective nonoperative management , operative treatment is now indicated for those patients that have failed nonoperative management. The principles of operative treatment of stage 2 deformities include transferring another tendon to help serve the role of the dysfunctional posterior tibial tendon (usually the flexor hallucis longus is transferred). Restoring the shape and alignment of the foot. This moves the weight bearing axis back to the center of the ankle. Changing the shape of the foot can be achieved by one or more of the following procedures. Cutting the heel bone and shifting it to the inside (Medializing calcaneal osteotomy). Lateral column lengthening restores the arch and overall alignment of the foot. Medial column stabilization. This stiffens the ray of the big toe to better support the arch. Lengthening of the Achilles tendon or Gastrocnemius. This will allow the ankle to move adequately once the alignment of the foot is corrected. Stage 3 acquired adult flatfoot deformity is treated operatively with a hindfoot fusion (arthrodesis). This is done with either a double or triple arthrodesis - fusion of two or three of the joints in hindfoot through which the deformity occurs. It is important when a hindfoot arthrodesis is performed that it be done in such a way that the underlying foot deformity is corrected first. Simply fusing the hindfoot joints in place is no longer acceptable.

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